Healthcare Provider Details

I. General information

NPI: 1568037471
Provider Name (Legal Business Name): VCU DENTAL FACULTY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

521 N 11TH ST
RICHMOND VA
23298-5016
US

IV. Provider business mailing address

520 N 12TH ST
RICHMOND VA
23298-5064
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-3368
  • Fax:
Mailing address:
  • Phone: 804-828-3769
  • Fax: 804-628-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY JACOBS
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 804-828-6514