Provider Demographics
NPI:1962813402
Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Other - Org Name:FAMILY DENTISTRY OF SHORT PUMP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:11549 NUCKOLS RD STE A
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5664
Mailing Address - Country:US
Mailing Address - Phone:804-527-2982
Mailing Address - Fax:804-527-2987
Practice Address - Street 1:11549 NUCKOLS RD STE A
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5664
Practice Address - Country:US
Practice Address - Phone:804-527-2982
Practice Address - Fax:804-527-2987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty