Healthcare Provider Details

I. General information

NPI: 1124579396
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY & ORTHODONTICS OF VA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 12/12/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13463 HULL STREET RD.
MIDLOTHIAN VA
23112-2103
US

IV. Provider business mailing address

13463 HULL STREET RD.
MIDLOTHIAN VA
23112-2103
US

V. Phone/Fax

Practice location:
  • Phone: 804-739-0963
  • Fax: 804-739-0965
Mailing address:
  • Phone: 804-739-0963
  • Fax: 804-739-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEVEN R. LUBBE
Title or Position: VICE PRESIDENT
Credential: D.M.D.
Phone: 804-739-0963