Provider Demographics
NPI:1851051320
Name:RESTORE DENTAL CENTER OF HAMPTON ROADS
Entity Type:Organization
Organization Name:RESTORE DENTAL CENTER OF HAMPTON ROADS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-490-7866
Mailing Address - Street 1:1 COLUMBUS CTR STE 600
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6760
Mailing Address - Country:US
Mailing Address - Phone:757-490-7866
Mailing Address - Fax:
Practice Address - Street 1:223 E CITY HALL AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1724
Practice Address - Country:US
Practice Address - Phone:757-490-7866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUGUST HOLDING CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty