Healthcare Provider Details

I. General information

NPI: 1366239758
Provider Name (Legal Business Name): JEFFREY FLETCHER MAZZOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 FOREST AVE
RICHMOND VA
23230-1729
US

IV. Provider business mailing address

6900 FOREST AVE
RICHMOND VA
23230-1729
US

V. Phone/Fax

Practice location:
  • Phone: 804-893-8692
  • Fax: 804-285-1292
Mailing address:
  • Phone: 804-893-8692
  • Fax: 804-285-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0442000542
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: