Healthcare Provider Details

I. General information

NPI: 1932735305
Provider Name (Legal Business Name): HAMPTON ROADS FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 KECOUGHTAN RD
HAMPTON VA
23669-4405
US

IV. Provider business mailing address

3709 KECOUGHTAN RD
HAMPTON VA
23669-4405
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-8507
  • Fax:
Mailing address:
  • Phone: 757-722-8507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GWEN G NEWTON
Title or Position: ADMINISTRATOR
Credential: BS
Phone: 757-722-8507