Healthcare Provider Details

I. General information

NPI: 1225149362
Provider Name (Legal Business Name): DR JOSEPH G VAUGHAN DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 SENECA TRL
RONCEVERTE WV
24970-1342
US

IV. Provider business mailing address

294 SENECA TRL
RONCEVERTE WV
24970-1342
US

V. Phone/Fax

Practice location:
  • Phone: 304-645-2333
  • Fax: 304-647-5932
Mailing address:
  • Phone: 304-645-2333
  • Fax: 304-647-5932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3268
License Number StateWV

VIII. Authorized Official

Name: MICHELLE RENEE BOSTIC
Title or Position: BUSINESS COORDINATOR
Credential:
Phone: 304-645-2333