Provider Demographics
NPI:1104007384
Name:ROANOKE ORAL SURGERY, INC.
Entity Type:Organization
Organization Name:ROANOKE ORAL SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCLUNG
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-362-5900
Mailing Address - Street 1:PO BOX 7889
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-0889
Mailing Address - Country:US
Mailing Address - Phone:540-362-5900
Mailing Address - Fax:540-366-5131
Practice Address - Street 1:6027 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4029
Practice Address - Country:US
Practice Address - Phone:540-362-5900
Practice Address - Fax:540-366-5131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010046731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty