Healthcare Provider Details

I. General information

NPI: 1467686311
Provider Name (Legal Business Name): JOEL CHARLES FLORY MFPT/CDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 PITTSBURGH AVE
FAIRMONT WV
26554-4162
US

IV. Provider business mailing address

514 PITTSBURGH AVE
FAIRMONT WV
26554-4162
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-8950
  • Fax: 304-366-3519
Mailing address:
  • Phone: 304-366-8950
  • Fax: 304-366-3519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number1028-9815
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number1028-9815
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number1028-9815
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: