Provider Demographics
NPI:1730627357
Name:PEDIATRIC DENTISTRY & ORTHODONTICS OF VA
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY & ORTHODONTICS OF VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:KEETON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:804-739-0963
Mailing Address - Street 1:651 SOUTHPARK BLVD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3617
Mailing Address - Country:US
Mailing Address - Phone:804-536-9815
Mailing Address - Fax:804-526-9866
Practice Address - Street 1:13841 HULL STREET RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2056
Practice Address - Country:US
Practice Address - Phone:804-739-0963
Practice Address - Fax:804-739-0965
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty