Healthcare Provider Details

I. General information

NPI: 1760578637
Provider Name (Legal Business Name): DRS BUSSEY MAYO & ARCHER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 VIKING DRIVE STE #215
VIRGINIA BEACH VA
23452
US

IV. Provider business mailing address

477 VIKING DRIVE STE #215
VIRGINIA BEACH VA
23452
US

V. Phone/Fax

Practice location:
  • Phone: 757-486-5428
  • Fax: 757-486-4826
Mailing address:
  • Phone: 757-486-5428
  • Fax: 757-486-4826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401006323
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401410052
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401004066
License Number StateVA

VIII. Authorized Official

Name: MS. SHANDALE MARIE GREGORY
Title or Position: BILLING FINANCIAL COORDINATOR
Credential:
Phone: 757-486-5155