Healthcare Provider Details

I. General information

NPI: 1548506975
Provider Name (Legal Business Name): TAZEWELL DENTAL SLEEP THERAPY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 BEN BOLT AVE
TAZEWELL VA
24651-9703
US

IV. Provider business mailing address

125 BEN BOLT AVE
TAZEWELL VA
24651-9703
US

V. Phone/Fax

Practice location:
  • Phone: 276-979-5796
  • Fax: 276-988-5866
Mailing address:
  • Phone: 276-979-5796
  • Fax: 276-988-5866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401005792
License Number StateVA

VIII. Authorized Official

Name: DR. RONALD WAYNE HOUSEHOLDER
Title or Position: OWNER
Credential: D.D.S
Phone: 276-979-5796