Healthcare Provider Details

I. General information

NPI: 1245383397
Provider Name (Legal Business Name): JULIAN WILLIAM FIELDS IV D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 LYNCH MILL RD
ALTAVISTA VA
24517-1150
US

IV. Provider business mailing address

2180 LYNCH MILL RD
ALTAVISTA VA
24517-1150
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-4702
  • Fax: 434-369-4703
Mailing address:
  • Phone: 434-369-4702
  • Fax: 434-369-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401008664
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: