=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386118990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA BEACH DENTAL SPA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2019
-----------------------------------------------------
Last Update Date | 01/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9305 QUIOCCASIN RD STE A
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-251-1233
-----------------------------------------------------
Fax | 804-750-1880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9305 QUIOCCASIN RD STE A
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-251-1233
-----------------------------------------------------
Fax | 804-750-1880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FIRAS ALBADRAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-505-7082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------