# LIFE BRIDGE DENTAL VA PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316603939
- **Authorized official:** MR. KENNETH N SULLIVAN (DIRECTOR RCM)
- **Authorized official phone:** (615) 601-5250

## Contact information

- **Practice address:** 4201 WILSON BLVD STE 190, ARLINGTON, VA 22203-4147
- **Practice address phone:** (212) 686-3686
- **Practice address fax:** (615) 468-0325
- **Mailing address:** DEPT CH 18077, PALATINE, IL 60055-8077
- **Mailing address phone:** (212) 686-3686
- **Mailing address fax:** (615) 468-0325

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |
| 1223X0400X | Orthodontics and Dentofacial Orthopedics Dentistry | — | NULL | — |
| 1223X0400X | Orthodontics and Dentofacial Orthopedics Dentistry | — | — | — |

## Other

- **Enumeration date:** 11/09/2021
- **Last updated:** 11/09/2021