MEDICARE: SPARKLE PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1821535444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKLE PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	11934 W BROAD ST STE 120
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1100
Country	:	US
Telephone Number	:	804-746-7382
Fax Number	:	804-746-3025

Provider Business Practice Location Address
First Line	:	11934 W BROAD ST STE 120
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1100
Country	:	US
Telephone Number	:	804-746-7382
Fax Number	:	804-746-3025

Authorized Official
Title or Position	:	PEDIATRIC DENTAL SPECIALIST
Name	:	HOLLY C LEWIS
Credential	:	DMD, MS
Telephone Number	:	804-746-7382

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	09/23/2021

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