Healthcare Provider Details

I. General information

NPI: 1720795131
Provider Name (Legal Business Name): RIVER RUN DENTAL OF LIBBIE MILL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 LIBBIE MILL EAST BLVD STE 125
RICHMOND VA
23230-2152
US

IV. Provider business mailing address

5001 LIBBIE MILL EAST BLVD STE 125
RICHMOND VA
23230-2152
US

V. Phone/Fax

Practice location:
  • Phone: 804-390-7133
  • Fax:
Mailing address:
  • Phone: 804-390-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: CHAD HENDRICKS
Title or Position: CREDENTIALING
Credential:
Phone: 612-859-0444