Healthcare Provider Details

I. General information

NPI: 1801067285
Provider Name (Legal Business Name): SOUTHSIDE ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11971 IRON BRIDGE RD
CHESTER VA
23831-1458
US

IV. Provider business mailing address

11971 IRON BRIDGE RD
CHESTER VA
23831-1458
US

V. Phone/Fax

Practice location:
  • Phone: 804-717-5275
  • Fax: 804-748-4017
Mailing address:
  • Phone: 804-717-5275
  • Fax: 804-748-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4685
License Number StateVA

VIII. Authorized Official

Name: DR. BRADLEY SCOTT TROTTER
Title or Position: DENTIST
Credential: D.D.S.
Phone: 804-717-5275