Healthcare Provider Details

I. General information

NPI: 1982653804
Provider Name (Legal Business Name): GEORGE EDWARD TOLSON IV D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD MCGUIRE VAMC DENTAL SERVICE (160)
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD DENTAL SERVICE (160)
RICHMOND VA
23249-0001
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-3210
  • Fax: 804-675-5952
Mailing address:
  • Phone: 804-675-3210
  • Fax: 804-675-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401410614
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number15833
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: