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General NPI Number Information
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NPI Number | 1922417112
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Entity Type | Organization
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Legal Business Name | DENTISTRY OF VIRGINIA BEACH, PLC
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Dates
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Enumeration Date | 08/13/2014
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Last Update Date | 08/13/2014
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Provider Practice Location Address
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Address Line | 1805 COLONIAL MEDICAL CT
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-3034
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Country | US
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Telephone | 757-961-4300
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Fax |
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Provider Business Mailing Address
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Address Line | 1805 COLONIAL MEDICAL CT
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-3034
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Country | US
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Telephone | 757-961-4300
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | JORGE PELAEZ
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Credential | DMD
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Telephone | 757-961-4300
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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 | 0401411435
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License Number State | VA
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