Provider Demographics
NPI:1285032995
Name:KONIKOFF DENTAL
Entity type:Organization
Organization Name:KONIKOFF DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-416-3342
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:757-416-1400
Mailing Address - Fax:757-257-0085
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:757-416-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty