Healthcare Provider Details

I. General information

NPI: 1134923683
Provider Name (Legal Business Name): DR. TARCISIO RIBEIRO SANTANA SR.
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12080 N SCENIC HWY
ROCKY GAP VA
24366-5026
US

IV. Provider business mailing address

12080 N SCENIC HWY
ROCKY GAP VA
24366-5026
US

V. Phone/Fax

Practice location:
  • Phone: 786-769-2428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401420172
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: