Provider Demographics
NPI:1790297604
Name:EASTERN VIRGINIA PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:EASTERN VIRGINIA PEDIATRIC DENTISTRY
Other - Org Name:A DIVISION OF ATLANTIC DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-627-7550
Mailing Address - Street 1:1806 HAMPTON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1682
Mailing Address - Country:US
Mailing Address - Phone:757-627-7550
Mailing Address - Fax:757-627-2634
Practice Address - Street 1:1806 HAMPTON BLVD STE A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1682
Practice Address - Country:US
Practice Address - Phone:757-627-7550
Practice Address - Fax:757-627-2634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010081031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty