Healthcare Provider Details

I. General information

NPI: 1073064317
Provider Name (Legal Business Name): CENTRAL VIRGINIA DENTAL CARE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/18/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 ROCK CREEK VILLA DRIVE SUITE F
QUINTON VA
23141
US

IV. Provider business mailing address

3215 ROCK CREEK VILLA DRIVE SUITE F
QUINTON VA
23141
US

V. Phone/Fax

Practice location:
  • Phone: 804-932-5396
  • Fax:
Mailing address:
  • Phone: 804-932-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401412111
License Number StateVA

VIII. Authorized Official

Name: LAURI HENDERSON
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 804-897-3600