Healthcare Provider Details

I. General information

NPI: 1891976148
Provider Name (Legal Business Name): VALLEY ORAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 STARKEY RD STE B
ROANOKE VA
24018-0618
US

IV. Provider business mailing address

4437 STARKEY RD STE B
ROANOKE VA
24018-0618
US

V. Phone/Fax

Practice location:
  • Phone: 540-774-5900
  • Fax: 540-776-3496
Mailing address:
  • Phone: 540-774-5900
  • Fax: 540-776-3496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401005671
License Number StateVA

VIII. Authorized Official

Name: MRS. CAROLINE D SHELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 540-774-5900