Provider Demographics
NPI:1972261527
Name:PRUDEN FAMILY DENTISTRY
Entity type:Organization
Organization Name:PRUDEN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-357-4121
Mailing Address - Street 1:2303 PRUDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4330
Mailing Address - Country:US
Mailing Address - Phone:757-539-9481
Mailing Address - Fax:
Practice Address - Street 1:2303 PRUDEN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4330
Practice Address - Country:US
Practice Address - Phone:757-539-9481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P MILTON COOK PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental