Healthcare Provider Details

I. General information

NPI: 1356320337
Provider Name (Legal Business Name): GARY LYNN NEWELL D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 INDIAN RIVER RD
VIRGINIA BEACH VA
23464-5320
US

IV. Provider business mailing address

617 WICKWOOD DR
CHESAPEAKE VA
23322-5877
US

V. Phone/Fax

Practice location:
  • Phone: 757-420-1507
  • Fax: 757-424-7920
Mailing address:
  • Phone: 757-547-1571
  • Fax: 757-424-7920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6412
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: