Provider Demographics
NPI:1740320241
Name:THE CENTER FOR RESTORATIVE COSMETIC & IMPLANT DENTISTRY
Entity type:Organization
Organization Name:THE CENTER FOR RESTORATIVE COSMETIC & IMPLANT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LYON
Authorized Official - Last Name:SHAUGHNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-425-2332
Mailing Address - Street 1:303 35TH ST
Mailing Address - Street 2:#103
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451
Mailing Address - Country:US
Mailing Address - Phone:757-425-2332
Mailing Address - Fax:757-428-8561
Practice Address - Street 1:303 35TH ST
Practice Address - Street 2:#103
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451
Practice Address - Country:US
Practice Address - Phone:757-425-2332
Practice Address - Fax:757-428-8561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========Medicare UPIN