Provider Demographics
NPI:1790848711
Name:PANDOLFI, PHILIP JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOSEPH
Last Name:PANDOLFI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GREGG ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1526
Mailing Address - Country:US
Mailing Address - Phone:804-734-5454
Mailing Address - Fax:
Practice Address - Street 1:300 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FORT GREGG ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801-1526
Practice Address - Country:US
Practice Address - Phone:804-734-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010070431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139547OtherANTHEM
VA00W209J01Medicare ID - Type Unspecified
VA139547OtherANTHEM