Healthcare Provider Details

I. General information

NPI: 1760771679
Provider Name (Legal Business Name): PENINSULA ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 OYSTER POINT RD SUITE D
NEWPORT NEWS VA
23602-6926
US

IV. Provider business mailing address

401 OYSTER POINT RD SUITE D
NEWPORT NEWS VA
23602-6926
US

V. Phone/Fax

Practice location:
  • Phone: 757-249-4203
  • Fax: 757-249-4208
Mailing address:
  • Phone: 757-249-4203
  • Fax: 757-249-4208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7301
License Number StateVA

VIII. Authorized Official

Name: DR. VICKI ROSS
Title or Position: PRESIDENT
Credential: DMD
Phone: 757-249-4203