Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 0401414834 | VA |
NPI | 1043697915 |
---|---|
Provider Name | Chester Mayo JR. |
First Address | Virginia Beach, VA 23452-7349 |
Second Address | Virginia Beach, VA 23452-7349 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2015 |
Last Update Date | 29/07/2019 |