MEDICARE: LADYSMITH DENTAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0401412257	VA

General Provider Information

NPI Number	:	1912346073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LADYSMITH DENTAL CENTER

Provider Business Mailing Address
First Line	:	18010 JEFFERSON DAVIS HWY
Second Line	:
City	:	RUTHER GLEN
State	:	VA
Zip	:	22546-2922
Country	:	US
Telephone Number	:	804-589-1491
Fax Number	:	804-589-1494

Provider Business Practice Location Address
First Line	:	18010 JEFFERSON DAVIS HWY
Second Line	:
City	:	RUTHER GLEN
State	:	VA
Zip	:	22546-2922
Country	:	US
Telephone Number	:	804-589-1491
Fax Number	:	804-589-1494

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KELLY LYNN ROTHENBERGER
Credential	:
Telephone Number	:	804-589-1491

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	06/21/2013

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