Provider Demographics
NPI:1386241792
Name:OLD DOMINION FAMILY DENTAL
Entity type:Organization
Organization Name:OLD DOMINION FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:804-270-3080
Mailing Address - Street 1:3290 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1812
Mailing Address - Country:US
Mailing Address - Phone:804-270-3080
Mailing Address - Fax:804-967-0144
Practice Address - Street 1:3290 CHURCH RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1812
Practice Address - Country:US
Practice Address - Phone:804-270-3080
Practice Address - Fax:804-967-0144
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty