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General NPI Number Information
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NPI Number | 1871010850
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Entity Type | Organization
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Legal Business Name | SOUTH HOLSTON DENTAL DESIGNS
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Dates
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Enumeration Date | 08/29/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 15325 LEE HWY
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City | BRISTOL
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State | VA
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Zip | 24202-4013
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Country | US
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Telephone | 276-466-9800
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Fax | 276-591-5959
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Provider Business Mailing Address
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Address Line | 15325 LEE HWY
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City | BRISTOL
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State | VA
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Zip | 24202-4013
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Country | US
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Telephone | 276-466-9800
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Fax | 276-591-5959
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Authorized Official
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Title or Position | ACCOUNTING
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Name | MRS. VALERIA MILLER
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Credential |
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Telephone | 276-466-9800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 0401008559
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License Number State | VA
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