=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740611797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LON BRYAN MEADER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2013
-----------------------------------------------------
Last Update Date | 12/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5505 INDIAN RIVER RD SUITE 200
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-424-1300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5505 INDIAN RIVER RD SUITE 200
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-424-1300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. LON BRYAN MEADER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 757-424-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 401007973
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------