Healthcare Provider Details

I. General information

NPI: 1841663820
Provider Name (Legal Business Name): CGLDDSMORGANTOWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 HOLLAND AVE
WESTOVER WV
26501-4209
US

IV. Provider business mailing address

406 HOLLAND AVE
WESTOVER WV
26501-4209
US

V. Phone/Fax

Practice location:
  • Phone: 304-296-3786
  • Fax:
Mailing address:
  • Phone: 304-296-3786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3633
License Number StateWV

VIII. Authorized Official

Name: CAROLINE LABRITZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 304-296-3786