Healthcare Provider Details

I. General information

NPI: 1215502125
Provider Name (Legal Business Name): VCU ORAL-FACIAL SURGERY AND SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 12TH ST
RICHMOND VA
23298-5064
US

IV. Provider business mailing address

520 N 12TH ST
RICHMOND VA
23298-5064
US

V. Phone/Fax

Practice location:
  • Phone: 804-628-6637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: SANDY KROSLACK
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 904-201-1428