Healthcare Provider Details

I. General information

NPI: 1235718628
Provider Name (Legal Business Name): TREVOR LILJENQUIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VCUHS DEPARTMENT OF OMFS RESIDENCY, 980566 1250 EAST MARSHAL ST
RICHMOND VA
23298-0566
US

IV. Provider business mailing address

VCUHS GME BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-628-6637
  • Fax:
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: