Basic Information
| Provider Information | |||||||||
| NPI: | 1770023210 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOFT PALATE DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14186 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235180186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576512082 | ||||||||
| FaxNumber: | 4074793846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1734 E LITTLE CREEK RD | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235184202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576512082 | ||||||||
| FaxNumber: | 4074793846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2017 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | TRINA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4842267023 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.