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General NPI Number Information
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NPI Number | 1962154252
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE DENTAL CARES, PC
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Dates
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Enumeration Date | 01/19/2022
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Last Update Date | 01/19/2022
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Provider Practice Location Address
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Address Line | 2731 S CRATER RD
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City | PETERSBURG
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State | VA
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Zip | 23805-2403
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Country | US
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Telephone | 804-732-8557
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Fax |
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Provider Business Mailing Address
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Address Line | 5231 HICKORY PARK DR STE E
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City | GLEN ALLEN
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State | VA
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Zip | 23059-2619
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Country | US
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Telephone | 804-290-8001
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. BARBARA HEPNER
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Credential |
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Telephone | 804-290-8001
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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 |
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License Number State |
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