Healthcare Provider Details

I. General information

NPI: 1144274382
Provider Name (Legal Business Name): COMMONWEALTH ORAL & FACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8503 PATTERSON AVE SUITE B
RICHMOND VA
23229-6442
US

IV. Provider business mailing address

PO BOX 71930
RICHMOND VA
23255-1930
US

V. Phone/Fax

Practice location:
  • Phone: 804-354-1600
  • Fax: 804-354-1607
Mailing address:
  • Phone: 804-354-1600
  • Fax: 804-354-1607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0135583-3
License Number StateVA

VIII. Authorized Official

Name: GWEN EVA KENNON
Title or Position: SENIOR BILLING SPECIALIST
Credential:
Phone: 804-354-1602