MEDICARE: VIRGINIA DEPARTMENT OF HEALTH

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	1223D0001X	Public Health Dentistry	0401005262	VA

General Provider Information

NPI Number	:	1407971864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGINIA DEPARTMENT OF HEALTH

Provider Business Mailing Address
First Line	:	3130 VICTORIA BLVD
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23661-1544
Country	:	US
Telephone Number	:	757-727-1172
Fax Number	:	757-727-1185

Provider Business Practice Location Address
First Line	:	1320 LASALLE AVE
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23669-3801
Country	:	US
Telephone Number	:	757-727-1140
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. LEN REAVES I
Credential	:	DDS
Telephone Number	:	757-727-1140

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/22/2020

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Directions to “VIRGINIA DEPARTMENT OF HEALTH ” Practice Location

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