Healthcare Provider Details

I. General information

NPI: 1639542814
Provider Name (Legal Business Name): HAMPTON ROADS PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6882 MAIN ST
GLOUCESTER VA
23061-5163
US

IV. Provider business mailing address

3120 KILN CREEK PKWY STE P
YORKTOWN VA
23693-5648
US

V. Phone/Fax

Practice location:
  • Phone: 804-695-2575
  • Fax: 804-695-2815
Mailing address:
  • Phone: 757-369-1754
  • Fax: 757-234-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401410912
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401412905
License Number StateVA

VIII. Authorized Official

Name: GRACE O DAVIS
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 757-369-1754