Provider Demographics
NPI:1972149789
Name:CD VIRGINIA DENTAL, P.C.
Entity Type:Organization
Organization Name:CD VIRGINIA DENTAL, P.C.
Other - Org Name:GENERAL & IMPLANT DENTISTRY OF TIDEWATER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-808-4984
Mailing Address - Street 1:9825 KENWOOD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6252
Mailing Address - Country:US
Mailing Address - Phone:513-609-4076
Mailing Address - Fax:513-448-0511
Practice Address - Street 1:836 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6126
Practice Address - Country:US
Practice Address - Phone:757-428-8747
Practice Address - Fax:757-422-8165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty