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General NPI Number Information
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NPI Number | 1144641309
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH DENTAL CLINIC
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Dates
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Enumeration Date | 12/13/2013
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Last Update Date | 12/13/2013
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Provider Practice Location Address
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Address Line | 1121 S JEFFERSON ST
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City | ROANOKE
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State | VA
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Zip | 24016-4703
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Country | US
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Telephone | 540-685-0028
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Fax |
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Provider Business Mailing Address
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Address Line | 1618 W MAIN ST
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City | SALEM
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State | VA
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Zip | 24153-3116
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Country | US
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Telephone | 540-685-0028
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GREGORY TODD HARVEY
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Credential | DMD
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Telephone | 540-685-0028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 0401410880
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License Number State | VA
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