Provider Demographics
NPI:1679978795
Name:COMMONWEALTH PEDIATRIC DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:COMMONWEALTH PEDIATRIC DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-875-6808
Mailing Address - Street 1:5506 WHITESIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:SANDSTON
Mailing Address - State:VA
Mailing Address - Zip Code:23150-2345
Mailing Address - Country:US
Mailing Address - Phone:617-875-6808
Mailing Address - Fax:
Practice Address - Street 1:5506 WHITESIDE ROAD
Practice Address - Street 2:
Practice Address - City:SANDSTON
Practice Address - State:VA
Practice Address - Zip Code:23150-2345
Practice Address - Country:US
Practice Address - Phone:617-875-6808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA401411512261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental