Healthcare Provider Details

I. General information

NPI: 1770895815
Provider Name (Legal Business Name): DANIEL W SUDIMACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 10/03/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 JACKSON RIVER RD
MONTEREY VA
24465
US

IV. Provider business mailing address

PO BOX 490
MONTEREY VA
24465-0490
US

V. Phone/Fax

Practice location:
  • Phone: 540-468-6400
  • Fax: 540-468-3316
Mailing address:
  • Phone: 540-468-6400
  • Fax: 540-468-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25701
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: