Provider Demographics
NPI:1235140716
Name:MOUNTAIN KIDS, INC.
Entity Type:Organization
Organization Name:MOUNTAIN KIDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:BUSKILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-988-5583
Mailing Address - Street 1:PO BOX 1298
Mailing Address - Street 2:200 EAST RIVERSIDE DRIVE
Mailing Address - City:NORTH TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-1298
Mailing Address - Country:US
Mailing Address - Phone:276-988-5583
Mailing Address - Fax:276-979-1441
Practice Address - Street 1:200 EAST RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24630
Practice Address - Country:US
Practice Address - Phone:276-988-5583
Practice Address - Fax:276-979-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9182558Medicaid