=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265544332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL COUNTY DENTAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 09/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 HIGHLAND DR STE A
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24266-7209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-889-7621
-----------------------------------------------------
Fax | 276-889-7695
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2347
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24266-2347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-889-7621
-----------------------------------------------------
Fax | 276-889-7695
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | REISA SLOCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 276-889-7621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------