=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164305421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH J. CAVALLARI, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2025
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 984 FIRST COLONIAL RD STE 300
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-3196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-412-0235
-----------------------------------------------------
Fax | 757-381-7123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 984 FIRST COLONIAL RD STE 300
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-3196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-412-0235
-----------------------------------------------------
Fax | 757-381-7123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR CREDENTIALING TEAM LEAD
-----------------------------------------------------
Name | JENNY GARCIA-ROCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------