Healthcare Provider Details

I. General information

NPI: 1245098391
Provider Name (Legal Business Name): UPPER MATTAPONI INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8014 RICHMOND TAPPAHANNOCK HWY
AYLETT VA
23009-3056
US

IV. Provider business mailing address

13476 KING WILLIAM RD
KING WILLIAM VA
23086-3401
US

V. Phone/Fax

Practice location:
  • Phone: 804-769-2015
  • Fax:
Mailing address:
  • Phone: 804-769-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVEN TUPPONCE
Title or Position: DIRECTOR-UMIT HEALTH SERVICES
Credential:
Phone: 804-347-4109