Healthcare Provider Details

I. General information

NPI: 1518837228
Provider Name (Legal Business Name): RIVER RUN DENTAL OF SEMINOLE TRAIL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 GREENBRIER PL
CHARLOTTESVILLE VA
22901-1697
US

IV. Provider business mailing address

1461 GREENBRIER PL
CHARLOTTESVILLE VA
22901-1697
US

V. Phone/Fax

Practice location:
  • Phone: 434-337-0515
  • Fax:
Mailing address:
  • Phone: 434-337-0515
  • Fax:

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 Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: KIM DAVIS
Title or Position: RCM DIRECTOR
Credential:
Phone: 703-568-5773