Basic Information
| Provider Information | |||||||||
| NPI: | 1790897221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | CONCEPCION | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CUNNINGHAM | ||||||||
| OtherFirstName: | AIMEE | ||||||||
| OtherMiddleName: | CONCEPCION | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579533917 | ||||||||
| FaxNumber: | 9127675425 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579533917 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN013365 | GA | N | Dental Providers | Dentist | General Practice | 122300000X | DN013365 | GA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | FC0072037 | 01 | DEA | OTHER |