Provider Demographics
NPI:1659844538
Name:KFD VIRGINIA INC
Entity Type:Organization
Organization Name:KFD VIRGINIA INC
Other - Org Name:KIDS FIRST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HABER
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-413-5100
Mailing Address - Street 1:4903 STARKEY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8525
Mailing Address - Country:US
Mailing Address - Phone:540-904-2700
Mailing Address - Fax:540-904-2760
Practice Address - Street 1:4903 STARKEY RD STE 300
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8525
Practice Address - Country:US
Practice Address - Phone:540-904-2700
Practice Address - Fax:540-904-2760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3691Medicaid