Healthcare Provider Details

I. General information

NPI: 1235140716
Provider Name (Legal Business Name): MOUNTAIN KIDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

200 EAST RIVERSIDE DRIVE
NORTH TAZEWELL VA
24630
US

IV. Provider business mailing address

PO BOX 1298 200 EAST RIVERSIDE DRIVE
NORTH TAZEWELL VA
24630-1298
US

V. Phone/Fax

Practice location:
  • Phone: 276-988-5583
  • Fax: 276-979-1441
Mailing address:
  • Phone: 276-988-5583
  • Fax: 276-979-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411127
License Number StateVA

VIII. Authorized Official

Name: DR. MARCUS BRANDON BUSKILL
Title or Position: DENTIST
Credential: DDS
Phone: 276-988-5583