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General NPI Number Information
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NPI Number | 1639542814
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Entity Type | Organization
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Legal Business Name | HAMPTON ROADS PEDIATRIC DENTISTRY AND ORTHODONTICS, PLLC
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Dates
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Enumeration Date | 11/10/2015
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Last Update Date | 04/12/2019
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Provider Practice Location Address
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Address Line | 6882 MAIN ST
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City | GLOUCESTER
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State | VA
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Zip | 23061-5163
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Country | US
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Telephone | 804-695-2575
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Fax | 804-695-2815
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Provider Business Mailing Address
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Address Line | 3120 KILN CREEK PKWY STE P
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City | YORKTOWN
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State | VA
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Zip | 23693-5648
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Country | US
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Telephone | 757-369-1754
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Fax | 757-234-8891
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Authorized Official
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Title or Position | BUSINESS ADMINISTRATOR
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Name | GRACE O DAVIS
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Credential |
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Telephone | 757-369-1754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 0401412905
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401410912
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License Number State | VA
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