MEDICARE: COLONIAL HEIGHTS DENTAL CARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401412257	VA

General Provider Information

NPI Number	:	1003352931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL HEIGHTS DENTAL CARE, INC.

Provider Business Mailing Address
First Line	:	2018 BOULEVARD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2310
Country	:	US
Telephone Number	:	804-520-1741
Fax Number	:	804-520-4750

Provider Business Practice Location Address
First Line	:	2018 BOULEVARD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2310
Country	:	US
Telephone Number	:	804-520-1741
Fax Number	:	804-520-4750

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. BASIONY HAGAR
Credential	:	D.D.S.
Telephone Number	:	804-520-1741

Provider Enumeration Date	:	01/17/2017
Last Update Date	:	01/17/2017

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