Healthcare Provider Details

I. General information

NPI: 1831125251
Provider Name (Legal Business Name): THOMAS WAYNE MOSTILER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6033 PROVIDENCE RD
VIRGINIA BEACH VA
23464-3815
US

IV. Provider business mailing address

6033 PROVIDENCE RD
VIRGINIA BEACH VA
23464-3815
US

V. Phone/Fax

Practice location:
  • Phone: 757-424-2672
  • Fax:
Mailing address:
  • Phone: 757-424-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401003515
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: