Provider Demographics
NPI:1487966339
Name:HEAVENLY SMILES DENTISTRY, PLLC
Entity type:Organization
Organization Name:HEAVENLY SMILES DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-892-1330
Mailing Address - Street 1:PO BOX 1059
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1059
Mailing Address - Country:US
Mailing Address - Phone:804-892-1330
Mailing Address - Fax:
Practice Address - Street 1:1100A BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3001
Practice Address - Country:US
Practice Address - Phone:804-892-1330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty