Provider Demographics
NPI:1750403911
Name:CHILDRENS ENDODONTIC SERVICES, PC
Entity type:Organization
Organization Name:CHILDRENS ENDODONTIC SERVICES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:NESBITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:804-733-6740
Mailing Address - Street 1:2010 WAKEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2112
Mailing Address - Country:US
Mailing Address - Phone:804-733-6740
Mailing Address - Fax:804-733-8687
Practice Address - Street 1:2010 WAKEFIELD AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2112
Practice Address - Country:US
Practice Address - Phone:804-733-6740
Practice Address - Fax:804-733-8687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014126701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225803Medicaid
TN5360OtherTENNESSEE DENTAL LICENSE
FLDN19669OtherFLORIDA LIMITED DENTAL LICENSE
VA0401412670OtherVIRGINIA DENTAL LICENSE
DCDEN1000852OtherWASHINGTON DC DENTAL LICENSE
FL004708800Medicaid
VA1184607756Medicaid
KY45003936Medicaid
KY60003308Medicaid