Healthcare Provider Details

I. General information

NPI: 1619167319
Provider Name (Legal Business Name): JOHN SCOTT REPASS SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2007
Last Update Date: 07/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HIGHLAND AVE SE 301 COMMUNITY MEDICAL BLDG
ROANOKE VA
24013-2253
US

IV. Provider business mailing address

102 HIGHLAND AVE SE 301 COMMUNITY MEDICAL BLDG
ROANOKE VA
24013-2253
US

V. Phone/Fax

Practice location:
  • Phone: 540-343-1769
  • Fax: 540-342-1606
Mailing address:
  • Phone: 540-343-1769
  • Fax: 540-342-1606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401003883
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3883
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: