Healthcare Provider Details

I. General information

NPI: 1891871604
Provider Name (Legal Business Name): WYTHE COUNTY HEALTH DEPT DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 WEST RIDGE ROAD
WYTHEVILLE VA
24382
US

IV. Provider business mailing address

750 WEST RIDGE ROAD
WYTHEVILLE VA
24382
US

V. Phone/Fax

Practice location:
  • Phone: 276-228-5507
  • Fax: 226-228-3392
Mailing address:
  • Phone: 276-228-5507
  • Fax: 226-228-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number0401002879
License Number StateVA

VIII. Authorized Official

Name: MRS. ANNA H STEVENS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 276-781-7450