Provider Demographics
NPI:1467052019
Name:PARKWAY PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:PARKWAY PEDIATRIC DENTISTRY, PLLC
Other - Org Name:PARKWAY PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:REOPELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-212-7428
Mailing Address - Street 1:5907 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3863
Mailing Address - Country:US
Mailing Address - Phone:701-212-7428
Mailing Address - Fax:
Practice Address - Street 1:3650 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4004
Practice Address - Country:US
Practice Address - Phone:540-989-3639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-31
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty