Healthcare Provider Details

I. General information

NPI: 1407971864
Provider Name (Legal Business Name): VIRGINIA DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 LASALLE AVE
HAMPTON VA
23669-3801
US

IV. Provider business mailing address

3130 VICTORIA BLVD
HAMPTON VA
23661-1544
US

V. Phone/Fax

Practice location:
  • Phone: 757-727-1140
  • Fax:
Mailing address:
  • Phone: 757-727-1172
  • Fax: 757-727-1185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number0401005262
License Number StateVA

VIII. Authorized Official

Name: DR. LEN REAVES I
Title or Position: DENTIST
Credential: DDS
Phone: 757-727-1140