Provider Demographics
NPI:1710647433
Name:SPARK DENTAL VA, PLLC
Entity Type:Organization
Organization Name:SPARK DENTAL VA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-478-7166
Mailing Address - Street 1:1540 ROCK SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6141
Mailing Address - Country:US
Mailing Address - Phone:615-672-7221
Mailing Address - Fax:
Practice Address - Street 1:235 LINDEN SQ
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-5875
Practice Address - Country:US
Practice Address - Phone:276-642-0043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty