MEDICARE: KFD VIRGINIA INC

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659844538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KFD VIRGINIA INC

Provider Business Mailing Address
First Line	:	4903 STARKEY RD STE 300
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-8525
Country	:	US
Telephone Number	:	540-904-2700
Fax Number	:	540-904-2760

Provider Business Practice Location Address
First Line	:	4903 STARKEY RD STE 300
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-8525
Country	:	US
Telephone Number	:	540-904-2700
Fax Number	:	540-904-2760

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT HABER ELLIS III
Credential	:	DMD
Telephone Number	:	803-413-5100

Provider Enumeration Date	:	01/03/2019
Last Update Date	:	04/10/2024

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Directions to “KFD VIRGINIA INC ” Practice Location

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