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General NPI Number Information
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NPI Number | 1821535444
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Entity Type | Organization
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Legal Business Name | SPARKLE PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 09/23/2021
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Provider Practice Location Address
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Address Line | 11934 W BROAD ST STE 120
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City | HENRICO
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State | VA
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Zip | 23233-1100
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Country | US
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Telephone | 804-746-7382
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Fax | 804-746-3025
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Provider Business Mailing Address
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Address Line | 11934 W BROAD ST STE 120
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City | HENRICO
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State | VA
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Zip | 23233-1100
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Country | US
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Telephone | 804-746-7382
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Fax | 804-746-3025
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Authorized Official
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Title or Position | PEDIATRIC DENTAL SPECIALIST
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Name | HOLLY C LEWIS
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Credential | DMD, MS
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Telephone | 804-746-7382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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