Provider Demographics
NPI:1871768390
Name:JEREMY SHULMAN
Entity type:Organization
Organization Name:JEREMY SHULMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:CUBITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-496-8070
Mailing Address - Street 1:2061 THOMAS BISHOP LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1129
Mailing Address - Country:US
Mailing Address - Phone:757-496-8070
Mailing Address - Fax:
Practice Address - Street 1:1301 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2263
Practice Address - Country:US
Practice Address - Phone:757-496-8070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010024881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA147713OtherANTHEM PROVIDER NUMBER
VA231794OtherCIGNA DENTAL
VA177146OtherUNITED CONCORDIA DENTAL
VAC08502040OtherSUBMITTER ID
VA231794OtherCIGNA DENTAL
VA147713OtherANTHEM PROVIDER NUMBER