=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649305467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREDOLOGOS FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1917 LASKIN RD STE 106
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-425-1828
-----------------------------------------------------
Fax | 757-425-1834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1917 LASKIN RD STE 106
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-425-1828
-----------------------------------------------------
Fax | 757-425-1834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARIA BREDOLOGOS MENDRINOS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 757-425-1828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401007153
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------