Provider Demographics
NPI:1114367695
Name:WEST VIRGINIA UNIVERSTIY DENTAL CORPORATION
Entity Type:Organization
Organization Name:WEST VIRGINIA UNIVERSTIY DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, DENTAL BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-293-2240
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1587
Mailing Address - Country:US
Mailing Address - Phone:304-293-6129
Mailing Address - Fax:304-293-7646
Practice Address - Street 1:451/453 SUNCREST TOWN CENTRE DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-293-2240
Practice Address - Fax:304-293-7646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9919421Medicare Oscar/Certification