Basic Information
| Provider Information | |||||||||
| NPI: | 1376736967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373646 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | GORMAN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LEAD DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 3216373646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | DH 17979 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.