Basic Information
| Provider Information | |||||||||
| NPI: | 1417977265 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLGRADE DENTAL CENTER PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2611 PROMENADE PKWY | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231131431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047946900 | ||||||||
| FaxNumber: | 8047947974 | ||||||||
| Practice Location | |||||||||
| Address1: | 2611 PROMENADE PKWY | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231131431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047946900 | ||||||||
| FaxNumber: | 8047947974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | THEWS | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8047946900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 4252 & 0401411077 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | AH5122837 | 01 | VA | DEA # | OTHER | BT9339739 | 01 | VA | DEA # | OTHER |