Healthcare Provider Details

I. General information

NPI: 1376736967
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 VETERANS WAY
MELBOURNE FL
32940-8007
US

IV. Provider business mailing address

2900 VETERANS WAY
MELBOURNE FL
32940-8007
US

V. Phone/Fax

Practice location:
  • Phone: 321-637-3646
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDH 17979
License Number StateFL

VIII. Authorized Official

Name: LISA GORMAN
Title or Position: LEAD DENTIST
Credential:
Phone: 321-637-3646