MEDICARE: SEABOARD DENTAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401008030	VA

General Provider Information

NPI Number	:	1114216843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEABOARD DENTAL SERVICES

Provider Business Mailing Address
First Line	:	1112 LASKIN ROAD SUITE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451
Country	:	US
Telephone Number	:	757-425-1335
Fax Number	:

Provider Business Practice Location Address
First Line	:	1112 LASKIN ROAD SUITE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451
Country	:	US
Telephone Number	:	757-425-1335
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR MANAGER
Name	:	RANDALL L BITTNER
Credential	:	DMD
Telephone Number	:	757-425-1335

Provider Enumeration Date	:	04/04/2011
Last Update Date	:	04/04/2011

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