Healthcare Provider Details

I. General information

NPI: 1003928938
Provider Name (Legal Business Name): NORTHUMBERLAND COUNTY DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6373 NORTHUMBERLAND HWY - SUITE B
HEATHSVILLE VA
22473
US

IV. Provider business mailing address

6373 NORTHUMBERLAND HWY - SUITE B P O BOX 69
HEATHSVILLE VA
22473
US

V. Phone/Fax

Practice location:
  • Phone: 804-758-2381
  • Fax: 804-758-4828
Mailing address:
  • Phone: 804-758-2381
  • Fax: 804-758-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number0401004548
License Number StateVA

VIII. Authorized Official

Name: DR. DANIEL LAWRENCE
Title or Position: HEALTH DEPT DENTIST
Credential: DDS
Phone: 804-758-2381