Provider Demographics
NPI:1548477649
Name:PENINSULA PEDIATRIC DENTISTRY, P.C.
Entity type:Organization
Organization Name:PENINSULA PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-369-1754
Mailing Address - Street 1:220 NAT TURNER BOULEVARD S
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 NAT TURNER BOULEVARD S
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-240-5711
Practice Address - Fax:757-240-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014109121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty