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General NPI Number Information
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NPI Number | 1255841433
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Entity Type | Organization
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Legal Business Name | ROANOKE PEDIATRIC DENTISTRY, LLC
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Dates
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Enumeration Date | 10/02/2017
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Last Update Date | 10/02/2017
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Provider Practice Location Address
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Address Line | 6112 PETERS CREEK RD
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City | ROANOKE
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State | VA
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Zip | 24019-4028
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Country | US
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Telephone | 540-563-1660
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Fax |
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Provider Business Mailing Address
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Address Line | 6112 PETERS CREEK RD
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City | ROANOKE
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State | VA
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Zip | 24019-4028
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Country | US
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Telephone | 540-563-1660
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. COREY JOE SHEPPARD
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Credential | DDS
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Telephone | 540-563-1660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401413481
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License Number State | VA
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