Provider Demographics
NPI:1366654808
Name:PEDIATRIC DENTAL CARE OF VIRGINIA
Entity type:Organization
Organization Name:PEDIATRIC DENTAL CARE OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:MALCHIJAH
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-293-2289
Mailing Address - Street 1:5126 KING'S MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078
Mailing Address - Country:US
Mailing Address - Phone:276-647-2033
Mailing Address - Fax:276-647-2034
Practice Address - Street 1:5126 KING'S MOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078
Practice Address - Country:US
Practice Address - Phone:276-647-2033
Practice Address - Fax:276-647-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014102191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty