Healthcare Provider Details

I. General information

NPI: 1790624179
Provider Name (Legal Business Name): MR. JITEN RALPH PEIRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 NEALY BLVD
HAMPTON VA
23665-2022
US

IV. Provider business mailing address

77 NEALY AVE
HAMPTON VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6824
  • Fax:
Mailing address:
  • Phone: 757-225-7630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: