=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093634891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEYGATE DENTAL SURGERY CENTER MIDLAND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2026
-----------------------------------------------------
Last Update Date | 07/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3225 SUNSET BLVD
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-3453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-406-9455
-----------------------------------------------------
Fax | 910-759-7441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 87701
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-7701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-406-9455
-----------------------------------------------------
Fax | 910-759-7441
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | VIRGINIA JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-406-9455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0004X
-----------------------------------------------------
Taxonomy Name | Dental Anesthesiology
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------