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General NPI Number Information
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NPI Number | 1720948052
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Entity Type | Organization
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Legal Business Name | CENTREVILLE PEDIATRIC DENTISTRY PLLC
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Dates
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Enumeration Date | 11/18/2025
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 14701 LEE HWY STE 107-108
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City | CENTREVILLE
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State | VA
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Zip | 20121-2137
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Country | US
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Telephone | 757-869-9916
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Fax | 757-898-4919
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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 | NEWPORT NEWS
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State | VA
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Zip | 23601-3651
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Country | US
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Telephone | 757-869-9916
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Fax | 757-898-4919
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Authorized Official
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Title or Position | RCM
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Name | CHRIS CANNON
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Credential |
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Telephone | 757-869-9916
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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 |
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License Number State |
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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 |
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License Number State |
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