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General NPI Number Information
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NPI Number | 1730623885
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Entity Type | Organization
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Legal Business Name | STADIUM DENTURE CENTER, INC.
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Dates
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Enumeration Date | 12/08/2016
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Last Update Date | 12/08/2016
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Provider Practice Location Address
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Address Line | 3015 DUDLEY AVE
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City | PARKERSBURG
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State | WV
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Zip | 26104-1817
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Country | US
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Telephone | 304-615-9852
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Fax |
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Provider Business Mailing Address
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Address Line | 3015 DUDLEY AVE
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City | PARKERSBURG
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State | WV
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Zip | 26104-1817
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Country | US
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Telephone | 304-615-9852
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARGIE ALLEN
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Credential |
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Telephone | 304-615-9852
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 292200000X
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Taxonomy Name | Dental Laboratory
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License Number | 1045-4114
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License Number State | WV
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