Provider Demographics
NPI:1932327277
Name:VIRGINIA COMMONWEALTH UNIVERSITY
Entity Type:Organization
Organization Name:VIRGINIA COMMONWEALTH UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ASSOCIATE DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MBA
Authorized Official - Phone:804-828-7978
Mailing Address - Street 1:520 N 12TH ST
Mailing Address - Street 2:LYONS BUILDING, ROOM 456, P.O. BOX 980566
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0566
Mailing Address - Country:US
Mailing Address - Phone:804-828-7978
Mailing Address - Fax:
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:LYONS BUILDING, ROOM 456
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0566
Practice Address - Country:US
Practice Address - Phone:804-828-7978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005311261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental