Healthcare Provider Details

I. General information

NPI: 1538256052
Provider Name (Legal Business Name): SMYTH CO HEALTH DEPT DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 FRANCIS MARION LANE
MARION VA
24375
US

IV. Provider business mailing address

201 FRANCIS MARION LANE
MARION VA
24354
US

V. Phone/Fax

Practice location:
  • Phone: 276-781-7460
  • Fax: 276-781-7465
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number0401005315
License Number StateVA

VIII. Authorized Official

Name: MRS. ANNA H STEVENS
Title or Position: BUSINESS MGR
Credential:
Phone: 276-781-7450