Provider Demographics
NPI:1801067285
Name:SOUTHSIDE ORAL & FACIAL SURGERY
Entity type:Organization
Organization Name:SOUTHSIDE ORAL & FACIAL SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-717-5275
Mailing Address - Street 1:11971 IRON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1458
Mailing Address - Country:US
Mailing Address - Phone:804-717-5275
Mailing Address - Fax:804-748-4017
Practice Address - Street 1:11971 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1458
Practice Address - Country:US
Practice Address - Phone:804-717-5275
Practice Address - Fax:804-748-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA46851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9185610Medicaid
219899OtherANTHEM BC&BS
219900OtherANTHEM BC&BS
386682OtherANTHEM BC&BS
386686OtherANTHEM BC&BS
259641OtherANTHEM BC&BS
VA9179952Medicaid
VA9202377Medicaid
005298OtherANTHEM BC&BS
005299OtherANTHEM BC&BS
386684OtherANTHEM BC&BS
VA9185611Medicaid
386682OtherANTHEM BC&BS
VA9179952Medicaid
001766B49Medicare PIN
U95426Medicare UPIN
VA9202377Medicaid
T21820Medicare UPIN
VA9185610Medicaid
190000595Medicare PIN