MEDICARE: LONG RIDGE DENTISTRY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1144714700	OTHER		NPI

General Provider Information

NPI Number	:	1083225429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG RIDGE DENTISTRY, PC

Provider Business Mailing Address
First Line	:	357 WINDIGROVE DR APT 326
Second Line	:
City	:	WAYNESBORO
State	:	VA
Zip	:	22980-7500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2780 STUARTS DRAFT HWY STE 102
Second Line	:
City	:	STUARTS DRAFT
State	:	VA
Zip	:	24477-2779
Country	:	US
Telephone Number	:	540-337-2400
Fax Number	:	540-337-4090

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HANNAH MABE
Credential	:	DDS
Telephone Number	:	434-249-8606

Provider Enumeration Date	:	08/10/2020
Last Update Date	:	08/10/2020

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