Healthcare Provider Details

I. General information

NPI: 1174584981
Provider Name (Legal Business Name): ROSSANO N WLODAWSKY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11319 POLO PL
MIDLOTHIAN VA
23113-1434
US

IV. Provider business mailing address

11545A NUCKOLS ROAD
GLEN ALLEN VA
23059-5666
US

V. Phone/Fax

Practice location:
  • Phone: 804-794-0794
  • Fax: 804-379-2858
Mailing address:
  • Phone: 804-673-8061
  • Fax: 804-673-5644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401410693
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0438000187
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: