Healthcare Provider Details

I. General information

NPI: 1801283874
Provider Name (Legal Business Name): WEST VIRGINIA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE ORAL SURGERY DEPARTMENT
MORGANTOWN WV
26506
US

IV. Provider business mailing address

PO BOX 9475 1 MEDICAL CENTER DRIVE
MORGANTOWN WV
26506
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-1127
  • Fax: 304-293-3674
Mailing address:
  • Phone: 304-293-1127
  • Fax: 304-293-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4076
License Number StateWV

VIII. Authorized Official

Name: DR. ASHLEY NICOLE CLARK
Title or Position: ASSISTANT PROFESSOR
Credential: DDS
Phone: 304-293-1127