Provider Demographics
NPI:1194540583
Name:IDEAL DENTAL STUDIO LLC
Entity type:Organization
Organization Name:IDEAL DENTAL STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:SEFAH
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:757-348-3011
Mailing Address - Street 1:3782 VIRGINIA BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3414
Mailing Address - Country:US
Mailing Address - Phone:757-348-3011
Mailing Address - Fax:
Practice Address - Street 1:3782 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-3414
Practice Address - Country:US
Practice Address - Phone:757-348-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty