Provider Demographics
NPI:1629224043
Name:SHENANDOAH VALLEY ORTHODONTIC SPECIALISTS, PC
Entity Type:Organization
Organization Name:SHENANDOAH VALLEY ORTHODONTIC SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:DEARMENT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-667-9662
Mailing Address - Street 1:1010 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3308
Mailing Address - Country:US
Mailing Address - Phone:540-667-9662
Mailing Address - Fax:540-722-0597
Practice Address - Street 1:1010 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3308
Practice Address - Country:US
Practice Address - Phone:540-667-9662
Practice Address - Fax:540-722-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010080141223X0400X
VA04014105671223X0400X
VA04010054221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1942370598Medicare PIN
VA1124198759Medicare PIN
VA1023188661Medicare PIN