Healthcare Provider Details

I. General information

NPI: 1043498231
Provider Name (Legal Business Name): SCOTT R GOODOVE DDS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2008
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 FIRST COLONIAL RD
VIRGINIA BEACH VA
23454-2402
US

IV. Provider business mailing address

1127 FIRST COLONIAL RD
VIRGINIA BEACH VA
23454-2402
US

V. Phone/Fax

Practice location:
  • Phone: 757-412-2002
  • Fax: 757-412-2003
Mailing address:
  • Phone: 757-412-2002
  • Fax: 757-412-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number401410548
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401410548
License Number StateVA

VIII. Authorized Official

Name: DR. SCOTT ROBBINS GOODOVE
Title or Position: CEO
Credential: DDS
Phone: 757-412-2002