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General NPI Number Information
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NPI Number | 1679978795
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH PEDIATRIC DENTAL SPECIALISTS
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Dates
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Enumeration Date | 10/31/2014
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Last Update Date | 10/31/2014
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Provider Practice Location Address
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Address Line | 5506 WHITESIDE ROAD
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City | SANDSTON
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State | VA
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Zip | 23150-2345
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Country | US
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Telephone | 617-875-6808
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Fax |
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Provider Business Mailing Address
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Address Line | 5506 WHITESIDE ROAD
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City | SANDSTON
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State | VA
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Zip | 23150-2345
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Country | US
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Telephone | 617-875-6808
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST/OWNER
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Name | DR. JOY PHELPS
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Credential | D.M.D.
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Telephone | 617-875-6808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 401411512
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License Number State | VA
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