=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871881912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABINGDON PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2011
-----------------------------------------------------
Last Update Date | 07/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 W MAIN ST
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24210-2630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-739-7942
-----------------------------------------------------
Fax | 276-739-7943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1925 465 W. MAIN STREET
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24212-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-739-7942
-----------------------------------------------------
Fax | 276-739-7943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIODONTIST
-----------------------------------------------------
Name | EVELYN M ROLON
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 276-739-7942
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401410901
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------