Provider Demographics
NPI:1023118403
Name:HUMPHREY, VIRGINIA POTTER II (DDS)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:POTTER
Last Name:HUMPHREY
Suffix:II
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VIRGINIA
Other - Middle Name:POTTER
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2603 SE MILITARY DRIVE
Mailing Address - Street 2:103
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223
Mailing Address - Country:US
Mailing Address - Phone:210-333-6911
Mailing Address - Fax:
Practice Address - Street 1:2603 SE MILITARY DRIVE
Practice Address - Street 2:103
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223
Practice Address - Country:US
Practice Address - Phone:210-333-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADI0357321223G0001X
TX25974122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice