Healthcare Provider Details

I. General information

NPI: 1457697690
Provider Name (Legal Business Name): ATLANTIC DENTAL CARE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S INDEPENDENCE BLVD STE 102
VIRGINIA BEACH VA
23452-1152
US

IV. Provider business mailing address

520 S INDEPENDENCE BLVD STE 102
VIRGINIA BEACH VA
23452-1152
US

V. Phone/Fax

Practice location:
  • Phone: 757-497-4825
  • Fax:
Mailing address:
  • Phone: 757-497-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401410283
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL EDUARDO FERNANDEZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 757-497-4825