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Provider Information for 1679834287

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1679834287

Calendar   Last Updated:  2012-05-31
  Certification Date: 


Name Value
NPI 1679834287
Enumeration Date 2012-05-31
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address PO BOX 84
KAYSVILLE, UT 84037-0084
United States

Phone: | Fax:
View Map External Link
Primary Practice Address 407 3RD AVE E
BIG STONE GAP, VA 24219-2365
United States

Phone: 276-523-0931 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist VA 0401413594