MEDICARE: POWHATAN GENTLE DENTISTRY PLC

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	122300000X	Dentist	0401410103	VA

General Provider Information

NPI Number	:	1043630569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWHATAN GENTLE DENTISTRY PLC

Provider Business Mailing Address
First Line	:	2105 ACADEMY RD
Second Line	:	UNIT J
City	:	POWHATAN
State	:	VA
Zip	:	23139-5829
Country	:	US
Telephone Number	:	804-598-8951
Fax Number	:	804-598-7527

Provider Business Practice Location Address
First Line	:	2105 ACADEMY RD
Second Line	:	UNIT J
City	:	POWHATAN
State	:	VA
Zip	:	23139-5829
Country	:	US
Telephone Number	:	804-598-8951
Fax Number	:	804-598-7527

Authorized Official
Title or Position	:	DENTIST AND OWNER
Name	:	DR. GENEVIEVE DEVERA
Credential	:
Telephone Number	:	804-598-8951

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	05/01/2014

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