MEDICARE: CD VIRGINIA DENTAL, P.C.

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
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1972149789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CD VIRGINIA DENTAL, P.C.

Provider Business Mailing Address
First Line	:	9825 KENWOOD RD STE 200
Second Line	:
City	:	BLUE ASH
State	:	OH
Zip	:	45242-6252
Country	:	US
Telephone Number	:	513-609-4076
Fax Number	:	513-448-0511

Provider Business Practice Location Address
First Line	:	836 FIRST COLONIAL RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6126
Country	:	US
Telephone Number	:	757-428-8747
Fax Number	:	757-422-8165

Authorized Official
Title or Position	:	DIRECTOR, PAYER RELATIONS
Name	:	TY JUSTICE
Credential	:
Telephone Number	:	513-808-4984

Provider Enumeration Date	:	11/27/2019
Last Update Date	:	03/07/2024

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