Healthcare Provider Details

I. General information

NPI: 1316603939
Provider Name (Legal Business Name): LIFE BRIDGE DENTAL VA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 WILSON BLVD STE 190
ARLINGTON VA
22203-4147
US

IV. Provider business mailing address

DEPT CH 18077
PALATINE IL
60055-8077
US

V. Phone/Fax

Practice location:
  • Phone: 212-686-3686
  • Fax: 615-468-0325
Mailing address:
  • Phone: 212-686-3686
  • Fax: 615-468-0325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH N SULLIVAN
Title or Position: DIRECTOR RCM
Credential:
Phone: 615-601-5250