MEDICARE: EAST COAST CENTRE FOR COSMETIC DENTISTRY AND FACIAL AESTHETICS

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	0401005366	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1770586216	OTHER		PERSONAL NPI NUMBER

General Provider Information

NPI Number	:	1558850776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST COAST CENTRE FOR COSMETIC DENTISTRY AND FACIAL AESTHETICS

Provider Business Mailing Address
First Line	:	3304 ARCTIC AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-2913
Country	:	US
Telephone Number	:	757-481-3305
Fax Number	:	757-481-7157

Provider Business Practice Location Address
First Line	:	3304 ARCTIC AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-2913
Country	:	US
Telephone Number	:	757-481-3305
Fax Number	:	757-481-7157

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STANLEY LEROY CHICKEY
Credential	:	DDS
Telephone Number	:	757-481-3305

Provider Enumeration Date	:	05/02/2018
Last Update Date	:	06/16/2018

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