Healthcare Provider Details

I. General information

NPI: 1619881596
Provider Name (Legal Business Name): PREMIER CARE DENTISTRY OF VIRGINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 S LABURNUM AVE STE 540
HENRICO VA
23231-2494
US

IV. Provider business mailing address

105 MAXESS RD STE 107N
MELVILLE NY
11747-3859
US

V. Phone/Fax

Practice location:
  • Phone: 804-567-8460
  • Fax:
Mailing address:
  • Phone: 631-414-7927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELA SWAIN
Title or Position: CREDENTIALING OPERATIONS MANAGER
Credential:
Phone: 516-344-5746