Provider Demographics
NPI:1548506975
Name:TAZEWELL DENTAL SLEEP THERAPY,LLC
Entity type:Organization
Organization Name:TAZEWELL DENTAL SLEEP THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HOUSEHOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-979-5796
Mailing Address - Street 1:125 BEN BOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-9703
Mailing Address - Country:US
Mailing Address - Phone:276-979-5796
Mailing Address - Fax:276-988-5866
Practice Address - Street 1:316 BEN BOLT AVE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-9703
Practice Address - Country:US
Practice Address - Phone:276-979-5796
Practice Address - Fax:276-988-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
VA0401005792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty