Healthcare Provider Details

I. General information

NPI: 1477112977
Provider Name (Legal Business Name): JOHN ROMAN BNINSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/30/2021
Certification Date: 04/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 SPRINGFIELD RD STE 101
GLEN ALLEN VA
23060-3410
US

IV. Provider business mailing address

4440 SPRINGFIELD RD STE 101
GLEN ALLEN VA
23060-3410
US

V. Phone/Fax

Practice location:
  • Phone: 804-217-9820
  • Fax: 804-459-8863
Mailing address:
  • Phone: 804-217-9820
  • Fax: 804-459-8863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401416543
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401416543
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: