Healthcare Provider Details

I. General information

NPI: 1629089750
Provider Name (Legal Business Name): COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 JEFFERSON DAVIS HWY
STAFFORD VA
22554-7213
US

IV. Provider business mailing address

608 JACKSON ST
FREDERICKSBURG VA
22401-5719
US

V. Phone/Fax

Practice location:
  • Phone: 540-288-2579
  • Fax: 540-288-3796
Mailing address:
  • Phone: 540-899-4797
  • Fax: 540-899-4599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JANE KRAKOWSKY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 540-899-4797