Healthcare Provider Details

I. General information

NPI: 1265813042
Provider Name (Legal Business Name): CHILDREN'S DENTISTRY OF CHARLOTTESVILLE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 PANTOPS MOUNTAIN PL
CHARLOTTESVILLE VA
22911-4600
US

IV. Provider business mailing address

1470 PANTOPS MOUNTAIN PL
CHARLOTTESVILLE VA
22911-4600
US

V. Phone/Fax

Practice location:
  • Phone: 434-817-1817
  • Fax: 434-817-1819
Mailing address:
  • Phone: 434-817-1817
  • Fax: 434-817-1819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401413819
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401412570
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number0401412934
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number0401413770
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401410463
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number753148626
License Number StateVA
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414088
License Number StateVA

VIII. Authorized Official

Name: DR. JOHN WILL
Title or Position: SHAREHOLDER
Credential: DDS
Phone: 434-817-1817