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General NPI Number Information
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NPI Number | 1104007384
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Entity Type | Organization
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Legal Business Name | ROANOKE ORAL SURGERY, INC.
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Dates
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Enumeration Date | 11/16/2007
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Last Update Date | 11/16/2007
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Provider Practice Location Address
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Address Line | 6027 PETERS CREEK RD
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City | ROANOKE
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State | VA
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Zip | 24019-4029
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Country | US
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Telephone | 540-362-5900
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Fax | 540-366-5131
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Provider Business Mailing Address
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Address Line | PO BOX 7889
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City | ROANOKE
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State | VA
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Zip | 24019-0889
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Country | US
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Telephone | 540-362-5900
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Fax | 540-366-5131
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES T. MCCLUNG JR.
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Credential | DDS
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Telephone | 540-362-5900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 0401004673
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License Number State | VA
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