Provider Demographics
NPI:1295960615
Name:FRIENDLY FACES PEDIACTRIC DENTISTRY
Entity type:Organization
Organization Name:FRIENDLY FACES PEDIACTRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERNITA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-397-9801
Mailing Address - Street 1:446 EFFINGHAM ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3416
Mailing Address - Country:US
Mailing Address - Phone:757-397-9801
Mailing Address - Fax:757-397-9805
Practice Address - Street 1:446 EFFINGHAM ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3416
Practice Address - Country:US
Practice Address - Phone:757-397-9801
Practice Address - Fax:757-397-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008200025Medicaid
NC8990115Medicaid