Provider Demographics
NPI:1821116120
Name:BATES, VIRGINIA C (DDS)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:C
Last Name:BATES
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 1:854 MARINA DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327
Mailing Address - Country:US
Mailing Address - Phone:954-873-0063
Mailing Address - Fax:318-352-0203
Practice Address - Street 1:854 MARINA DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33327-2122
Practice Address - Country:US
Practice Address - Phone:954-873-0063
Practice Address - Fax:318-352-0203
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1837555Medicaid