Healthcare Provider Details

I. General information

NPI: 1265579866
Provider Name (Legal Business Name): MARK DAVID LASSITER SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8487 S SCENIC HWY
BLAND VA
24315-4691
US

IV. Provider business mailing address

8487 S SCENIC HWY
BLAND VA
24315-4691
US

V. Phone/Fax

Practice location:
  • Phone: 276-688-4711
  • Fax: 276-688-4712
Mailing address:
  • Phone: 276-688-4711
  • Fax: 276-688-4712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6451
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: