Healthcare Provider Details

I. General information

NPI: 1912067141
Provider Name (Legal Business Name): TODD WILLIAM NEILS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 NIDER BLVD
NORFOLK VA
23521-2701
US

IV. Provider business mailing address

3612 E STRATFORD RD
VIRGINIA BEACH VA
23455-2949
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7435
  • Fax: 757-314-7441
Mailing address:
  • Phone: 757-314-7435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1786
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: