Provider Demographics
NPI:1063570968
Name:KONIKOFF DENTAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:KONIKOFF DENTAL ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP INSURANCE PLAN MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-424-2990
Mailing Address - Street 1:2100 LYNNHAVEN PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-1492
Mailing Address - Country:US
Mailing Address - Phone:757-416-1800
Mailing Address - Fax:757-416-9276
Practice Address - Street 1:2100 LYNNHAVEN PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1492
Practice Address - Country:US
Practice Address - Phone:757-416-1800
Practice Address - Fax:757-416-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA019711OtherANTHEM
816276OtherUNITED CONCORDIA