Provider Demographics
NPI:1720159437
Name:NANSEMOND SUFFOLK ORAL CARE
Entity Type:Organization
Organization Name:NANSEMOND SUFFOLK ORAL CARE
Other - Org Name:DR WYATT M RUFFIN JR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUFFIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-465-4884
Mailing Address - Street 1:3940 AIRLINE BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3329
Mailing Address - Country:US
Mailing Address - Phone:757-465-4884
Mailing Address - Fax:757-465-4884
Practice Address - Street 1:3940 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3329
Practice Address - Country:US
Practice Address - Phone:757-465-4884
Practice Address - Fax:757-465-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7821743Medicaid