Provider Demographics
NPI:1558414474
Name:LAVINDER, MICHAEL EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:LAVINDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 KINGS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-1826
Mailing Address - Country:US
Mailing Address - Phone:276-647-1494
Mailing Address - Fax:276-647-1142
Practice Address - Street 1:4940 KINGS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-1826
Practice Address - Country:US
Practice Address - Phone:276-647-1494
Practice Address - Fax:276-647-1142
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010053431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9181658OtherDORAL PROVIDER FOR MEDICA
VA816711OtherUNITED CONCORDIA
VA066633OtherANTHEM