Provider Demographics
NPI:1790528784
Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:3911 CHALLENGER AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-6733
Mailing Address - Country:US
Mailing Address - Phone:540-581-8095
Mailing Address - Fax:540-581-8096
Practice Address - Street 1:3911 CHALLENGER AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-6733
Practice Address - Country:US
Practice Address - Phone:540-581-8095
Practice Address - Fax:540-581-8096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF VIRGINIA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty