Provider Demographics
NPI: | 1629483466 |
---|---|
Name: | JEBEDIAH S CHRISTY, D.D.S. - VIENNA, PLLC |
Entity Type: | Organization |
Organization Name: | JEBEDIAH S CHRISTY, D.D.S. - VIENNA, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRS |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JASON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BERTOLLINI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 866-273-8204 |
Mailing Address - Street 1: | PO BOX 3189 |
Mailing Address - Street 2: | |
Mailing Address - City: | SYRACUSE |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 13220-3189 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 866-273-8204 |
Mailing Address - Fax: | 866-803-4943 |
Practice Address - Street 1: | 501 GRAND CENTRAL AVE |
Practice Address - Street 2: | |
Practice Address - City: | VIENNA |
Practice Address - State: | WV |
Practice Address - Zip Code: | 26105-2140 |
Practice Address - Country: | US |
Practice Address - Phone: | 866-273-8204 |
Practice Address - Fax: | 866-803-4943 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-06-30 |
Last Update Date: | 2014-06-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WV | 4081 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |