Healthcare Provider Details

I. General information

NPI: 1316969736
Provider Name (Legal Business Name): PETER W EISENHARDT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 HYDRAULIC RIDGE RD
CHARLOTTESVILLE VA
22901-8124
US

IV. Provider business mailing address

244 HYDRAULIC RIDGE RD
CHARLOTTESVILLE VA
22901-8124
US

V. Phone/Fax

Practice location:
  • Phone: 434-973-3348
  • Fax: 434-977-5790
Mailing address:
  • Phone: 434-973-3348
  • Fax: 434-977-5790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401006186
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: