Healthcare Provider Details

I. General information

NPI: 1386714996
Provider Name (Legal Business Name): APPALACHIAN ORAL & MAXILLOFACIAL SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 PARK BLVD
MARION VA
24354-4223
US

IV. Provider business mailing address

645 PARK BLVD
MARION VA
24354-4223
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-8131
  • Fax: 276-783-1839
Mailing address:
  • Phone: 276-783-8131
  • Fax: 276-783-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411670
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401005753
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401410162
License Number StateVA

VIII. Authorized Official

Name: DR. NEIL D HOLLYFIELD
Title or Position: PRESIDENT
Credential: DDS
Phone: 276-783-8131