Provider Demographics
NPI:1871652610
Name:PURSIFULL, KRIEG PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRIEG
Middle Name:PHILLIP
Last Name:PURSIFULL
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 1:132 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:FLOYD
Mailing Address - State:VA
Mailing Address - Zip Code:24091-2103
Mailing Address - Country:US
Mailing Address - Phone:540-745-4902
Mailing Address - Fax:
Practice Address - Street 1:132 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-2103
Practice Address - Country:US
Practice Address - Phone:540-745-4902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA049231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA065975OtherANTHEM
VA7811517Medicaid