Healthcare Provider Details

I. General information

NPI: 1851992234
Provider Name (Legal Business Name): ALTHEA ROACHE MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 RIVER RD
NORTH PRINCE GEORGE VA
23860-1666
US

IV. Provider business mailing address

1060 RIVER RD
NORTH PRINCE GEORGE VA
23860-1666
US

V. Phone/Fax

Practice location:
  • Phone: 804-504-7200
  • Fax: 804-504-7225
Mailing address:
  • Phone: 804-504-7200
  • Fax: 804-504-7225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number043417-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: