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General NPI Number Information
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NPI Number | 1326371048
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Entity Type | Organization
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Legal Business Name | PERIODONTAL HEALTH ASSOCIATES
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Dates
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Enumeration Date | 09/14/2009
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Last Update Date | 09/14/2009
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Provider Practice Location Address
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Address Line | 525 LEESVILLE RD
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City | LYNCHBURG
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State | VA
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Zip | 24502-2328
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Country | US
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Telephone | 434-455-2444
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Fax | 434-237-2050
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Provider Business Mailing Address
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Address Line | 525 LEESVILLE RD
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City | LYNCHBURG
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State | VA
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Zip | 24502-2328
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Country | US
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Telephone | 434-455-2444
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Fax | 434-237-2050
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHERMAN OWEN SMOCK
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Credential | D.D.S.
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Telephone | 434-455-2444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 005531
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License Number State | VA
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