Provider Demographics
NPI:1265889570
Name:DARCHELLE BRAXTON DMD PC
Entity type:Organization
Organization Name:DARCHELLE BRAXTON DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:804-709-8166
Mailing Address - Street 1:4300 POUNCEY TRACT ROAD SUITE I
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060
Mailing Address - Country:US
Mailing Address - Phone:804-709-8166
Mailing Address - Fax:
Practice Address - Street 1:4300 POUNCEY TRACT ROAD SUITE I
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:804-709-8166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014142431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA03647894Medicaid