Healthcare Provider Details

I. General information

NPI: 1881642593
Provider Name (Legal Business Name): JOSE G PEDROZA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 LAKE POINT DR
CHESAPEAKE VA
23320-7481
US

IV. Provider business mailing address

1218 LAKE POINT DR
CHESAPEAKE VA
23320-7481
US

V. Phone/Fax

Practice location:
  • Phone: 904-434-3035
  • Fax:
Mailing address:
  • Phone: 904-434-3035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19024714
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number51534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: