Organization
LIFE BRIDGE DENTAL VA PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KENNETH N SULLIVAN (DIRECTOR RCM)
(615) 601-5250
Entity
Organization
Contact information
Practice address
4201 WILSON BLVD STE 190, ARLINGTON, VA 22203-4147
(212) 686-3686
(615) 468-0325
Mailing address
DEPT CH 18077, PALATINE, IL 60055-8077
(212) 686-3686
(615) 468-0325
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
—
—
Other
Enumeration date
11/09/2021
Last updated
11/09/2021
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