Healthcare Provider Details

I. General information

NPI: 1053394585
Provider Name (Legal Business Name): RONALD L TANKERSLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 DENBIGH BLVD
NEWPORT NEWS VA
23608-4414
US

IV. Provider business mailing address

1404 RIVERS EDGE RD.
NEWPORT NEWS VA
23606
US

V. Phone/Fax

Practice location:
  • Phone: 757-874-6501
  • Fax:
Mailing address:
  • Phone: 757-874-6501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3791
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: