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General NPI Number Information
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NPI Number | 1972940393
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Entity Type | Organization
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Legal Business Name | SHENANDOAH ORAL & MAXILLOFACIAL SURGERY INC
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Dates
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Enumeration Date | 05/24/2013
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Last Update Date | 09/18/2019
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Provider Practice Location Address
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Address Line | 170 GARBER LN
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City | WINCHESTER
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State | VA
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Zip | 22602-4386
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Country | US
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Telephone | 540-667-0100
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Fax | 540-667-0121
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Provider Business Mailing Address
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Address Line | 170 GARBER LN
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City | WINCHESTER
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State | VA
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Zip | 22602-4386
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Country | US
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Telephone | 540-667-0100
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Fax | 540-667-0121
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | TARA ANN FUGATE
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Credential |
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Telephone | 703-897-8983
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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 | 0401006414
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License Number State | VA
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