Provider Demographics
NPI:1962154252
Name:SOUTHSIDE DENTAL CARES, PC
Entity type:Organization
Organization Name:SOUTHSIDE DENTAL CARES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEPNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-290-8001
Mailing Address - Street 1:5231 HICKORY PARK DR STE E
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-2619
Mailing Address - Country:US
Mailing Address - Phone:804-290-8001
Mailing Address - Fax:
Practice Address - Street 1:2731 S CRATER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2403
Practice Address - Country:US
Practice Address - Phone:804-732-8557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental