# VCU DENTAL FACULTY PRACTICE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** DENTISTRY@VCU
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1568037471
- **Legal business name:** DENTISTRY@VCU
- **Authorized official:** KIMBERLY JACOBS (DIRECTOR OF FINANCE)
- **Authorized official phone:** (804) 828-6514

## Contact information

- **Practice address:** 521 N 11TH ST, RICHMOND, VA 23298-5016
- **Practice address phone:** (804) 828-3368
- **Mailing address:** 520 N 12TH ST, RICHMOND, VA 23298-5064
- **Mailing address phone:** (804) 828-3769
- **Mailing address fax:** (804) 628-2001

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |
| 1223P0300X | Periodontics | — | NULL | — |
| 1223P0300X | Periodontics | — | — | — |
| 1223P0700X | Prosthodontics | — | NULL | — |
| 1223P0700X | Prosthodontics | — | — | — |

## Other

- **Enumeration date:** 05/24/2021
- **Last updated:** 05/24/2021