Healthcare Provider Details

I. General information

NPI: 1902699077
Provider Name (Legal Business Name): RIVERSIDE OFS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E MAIN ST
PURCELLVILLE VA
20132-3128
US

IV. Provider business mailing address

740 E MAIN ST
PURCELLVILLE VA
20132-3128
US

V. Phone/Fax

Practice location:
  • Phone: 540-404-8137
  • Fax: 540-254-5714
Mailing address:
  • Phone: 540-404-8137
  • Fax: 540-254-5714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DUSTIN H BOWLER
Title or Position: OWNER
Credential: DDS
Phone: 540-404-8137