Provider Demographics
NPI:1689299067
Name:VINSON, LIARA DESTINY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIARA
Middle Name:DESTINY
Last Name:VINSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E BYRD ST APT 6701
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-4310
Mailing Address - Country:US
Mailing Address - Phone:215-870-6587
Mailing Address - Fax:
Practice Address - Street 1:1000 E BROAD ST FL 6
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1930
Practice Address - Country:US
Practice Address - Phone:804-828-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043071122300000X
390200000X
VA04014179711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program