Healthcare Provider Details

I. General information

NPI: 1164305421
Provider Name (Legal Business Name): KENNETH J. CAVALLARI, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

984 FIRST COLONIAL RD STE 300
VIRGINIA BEACH VA
23454-3196
US

IV. Provider business mailing address

984 FIRST COLONIAL RD STE 300
VIRGINIA BEACH VA
23454-3196
US

V. Phone/Fax

Practice location:
  • Phone: 757-412-0235
  • Fax: 757-381-7123
Mailing address:
  • Phone: 757-412-0235
  • Fax: 757-381-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: JENNY GARCIA-ROCHA
Title or Position: SR CREDENTIALING TEAM LEAD
Credential:
Phone: 972-869-3789