Provider Demographics
NPI:1821535444
Name:SPARKLE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SPARKLE PEDIATRIC DENTISTRY
Other - Org Name:SPARKLE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTAL SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:804-746-7382
Mailing Address - Street 1:11934 W BROAD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1100
Mailing Address - Country:US
Mailing Address - Phone:804-746-7382
Mailing Address - Fax:804-746-3025
Practice Address - Street 1:11934 W BROAD ST STE 120
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1100
Practice Address - Country:US
Practice Address - Phone:804-746-7382
Practice Address - Fax:804-746-3025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-20
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty