MEDICARE: CHILDREN'S DENTISTRY OF VIRGINIA, PC

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	261QD0000X	Dental Clinic/Center	0401411465	VA

General Provider Information

NPI Number	:	1417116526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTISTRY OF VIRGINIA, PC

Provider Business Mailing Address
First Line	:	8316 WILLOW RIDGE PL
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-3296
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 COLONY CROSSING PL
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4281
Country	:	US
Telephone Number	:	804-639-6445
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN FLOWERS
Credential	:
Telephone Number	:	804-639-6445

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	06/04/2008

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