Healthcare Provider Details

I. General information

NPI: 1306973631
Provider Name (Legal Business Name): MAYNARD-RICHARDSON-OVERSTREET, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 GROVE AVE
RICHMOND VA
23226-1649
US

IV. Provider business mailing address

4909 GROVE AVE
RICHMOND VA
23226-1649
US

V. Phone/Fax

Practice location:
  • Phone: 804-355-6593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: BETSY A HAWKINS
Title or Position: OFFICE MANAGER
Credential:
Phone: 804-355-6593