Healthcare Provider Details

I. General information

NPI: 1578247094
Provider Name (Legal Business Name): PENINSULA PERIODONTICS AND IMPLANTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1194 BIG BETHEL RD STE B
HAMPTON VA
23666-1906
US

IV. Provider business mailing address

7151 RICHMOND RD STE 305
WILLIAMSBURG VA
23188-7234
US

V. Phone/Fax

Practice location:
  • Phone: 757-850-2100
  • Fax:
Mailing address:
  • Phone: 757-258-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MS. CELESTE VAUGHN
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 757-258-7778