Provider Demographics
NPI:1831680172
Name:REAL LIFE SEVENTEEN
Entity Type:Organization
Organization Name:REAL LIFE SEVENTEEN
Other - Org Name:REAL LIFE SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:B
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-552-5433
Mailing Address - Street 1:250 S MAIN ST STE 300A
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-4726
Mailing Address - Country:US
Mailing Address - Phone:540-552-5433
Mailing Address - Fax:540-552-2273
Practice Address - Street 1:202 S MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-4837
Practice Address - Country:US
Practice Address - Phone:540-443-9285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4014155041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty