Provider Demographics
NPI:1689942377
Name:FAMILY DENTAL OF VIRGINIA, LLC
Entity Type:Organization
Organization Name:FAMILY DENTAL OF VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-838-1649
Mailing Address - Street 1:2040 COLISEUM DR
Mailing Address - Street 2:STE. A27
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-3200
Mailing Address - Country:US
Mailing Address - Phone:757-262-0020
Mailing Address - Fax:
Practice Address - Street 1:2040 COLISEUM DR
Practice Address - Street 2:STE. A27
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3200
Practice Address - Country:US
Practice Address - Phone:757-262-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty