Provider Demographics
NPI:1265813042
Name:CHILDREN'S DENTISTRY OF CHARLOTTESVILLE, P.C.
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY OF CHARLOTTESVILLE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:434-817-1817
Mailing Address - Street 1:1470 PANTOPS MOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-4600
Mailing Address - Country:US
Mailing Address - Phone:434-817-1817
Mailing Address - Fax:434-817-1819
Practice Address - Street 1:1470 PANTOPS MOUNTAIN PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4600
Practice Address - Country:US
Practice Address - Phone:434-817-1817
Practice Address - Fax:434-817-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413819122300000X
VA0401412570122300000X
VA04014129341223D0004X
VA04014137701223D0004X
VA04014104631223P0221X
VA7531486261223S0112X
VA0401414088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty