Provider Demographics
NPI:1831629419
Name:HAMPTON ROADS ANESTHESIA & DENTISTRY, PLLC
Entity type:Organization
Organization Name:HAMPTON ROADS ANESTHESIA & DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-598-2958
Mailing Address - Street 1:303 55TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-2213
Mailing Address - Country:US
Mailing Address - Phone:757-598-2958
Mailing Address - Fax:757-425-1762
Practice Address - Street 1:1206 LASKIN RD STE 140
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-5267
Practice Address - Country:US
Practice Address - Phone:757-598-2958
Practice Address - Fax:757-425-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04470000451223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Single Specialty