=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750403911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDRENS ENDODONTIC SERVICES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 11/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 WAKEFIELD AVE
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-733-6740
-----------------------------------------------------
Fax | 804-733-8687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 WAKEFIELD AVE
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-733-6740
-----------------------------------------------------
Fax | 804-733-8687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAULA EVETTE NESBITT
-----------------------------------------------------
Credential | DDS MSD
-----------------------------------------------------
Telephone | 804-733-6740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 0401412670
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------