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General NPI Number Information
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NPI Number | 1710013446
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE ORAL SURGERY, INC.
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 07/10/2013
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Provider Practice Location Address
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Address Line | 54 S. MEDICAL PARK DRIVE
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City | FISHERSVILLE
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State | VA
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Zip | 22939-2333
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Country | US
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Telephone | 540-886-2956
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Fax | 540-886-2284
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Provider Business Mailing Address
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Address Line | 54 S. MEDICAL PARK DRIVE
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City | FISHERSVILLE
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State | VA
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Zip | 22939-2333
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Country | US
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Telephone | 540-886-2956
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Fax | 540-886-2284
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Authorized Official
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Title or Position | PRESIDENT
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Name | MATTHEW TODD BRANDT
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Credential | D.D.S., M.D.
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Telephone | 540-886-2956
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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 | 0438000074
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 0401410707
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 0438000220
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License Number State | VA
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