Provider Demographics
NPI:1316233851
Name:FRIEND, BASIL JACKSON II (DDS)
Entity type:Individual
Prefix:DR
First Name:BASIL
Middle Name:JACKSON
Last Name:FRIEND
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15806 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5202
Mailing Address - Country:US
Mailing Address - Phone:804-520-8994
Mailing Address - Fax:
Practice Address - Street 1:15806 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-5202
Practice Address - Country:US
Practice Address - Phone:804-520-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010071351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice