Provider Demographics
NPI:1265544332
Name:RUSSELL COUNTY DENTAL CLINIC
Entity type:Organization
Organization Name:RUSSELL COUNTY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:REISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SLOCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-889-7621
Mailing Address - Street 1:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-2347
Mailing Address - Country:US
Mailing Address - Phone:276-889-7621
Mailing Address - Fax:276-889-7695
Practice Address - Street 1:133 HIGHLAND DR STE A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-7209
Practice Address - Country:US
Practice Address - Phone:276-889-7621
Practice Address - Fax:276-889-7695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherFEDERAL TAX ID NUMBER