Healthcare Provider Details

I. General information

NPI: 1427072404
Provider Name (Legal Business Name): BRYAN M KONIKOFF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 VIKING DR SUITE 190
VIRGINIA BEACH VA
23452-7349
US

IV. Provider business mailing address

477 VIKING DR SUITE 190
VIRGINIA BEACH VA
23452-7349
US

V. Phone/Fax

Practice location:
  • Phone: 757-486-8181
  • Fax: 757-463-0148
Mailing address:
  • Phone: 757-486-8181
  • Fax: 757-463-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401410766
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: