Provider Demographics
NPI:1780853259
Name:WILLIAM B. PRUDEN, D.M.D., P.L.C.
Entity Type:Organization
Organization Name:WILLIAM B. PRUDEN, D.M.D., P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:PRUDEN
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-549-8077
Mailing Address - Street 1:1421 KEMPSVILLE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1406
Mailing Address - Country:US
Mailing Address - Phone:757-549-8077
Mailing Address - Fax:757-549-4497
Practice Address - Street 1:1421 KEMPSVILLE RD
Practice Address - Street 2:SUITE C
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1406
Practice Address - Country:US
Practice Address - Phone:757-549-8077
Practice Address - Fax:757-549-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA258032OtherBC/BS OF VIRGINIA
VA2QB260OtherBC/BS OF MASSACHUSETTS
VA7801106Medicaid
322736OtherBC/BS
VA1574OtherDOMINION DENTAL CO.