Healthcare Provider Details

I. General information

NPI: 1043717457
Provider Name (Legal Business Name): CHESAPEAKE FAMILY AND IMPLANT DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHESAPEAKE FAMILY AND IMPLANT DENTISTRY 516 INNOVATION DR. SUITE 302
CHESAPEAKE VA
23320
US

IV. Provider business mailing address

CHESAPEAKE FAMILY AND IMPLANT DENTISTRY LLC 516 INNOVATION DR. SUITE 302
CHESAPEAKE VA
23320
US

V. Phone/Fax

Practice location:
  • Phone: 757-436-0026
  • Fax: 757-547-5658
Mailing address:
  • Phone: 757-436-0026
  • Fax: 757-547-5658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401006063
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number0401006063
License Number StateVA

VIII. Authorized Official

Name: MS. PATTY LYNN HEBERLING
Title or Position: OFFICE MANAGER
Credential:
Phone: 757-436-0026