Provider Demographics
NPI:1871680082
Name:ROANOKE CO/SALEM DENTAL CLINIC
Entity Type:Organization
Organization Name:ROANOKE CO/SALEM DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER A
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-857-7800
Mailing Address - Street 1:105 E. CALHOUN STREET
Mailing Address - Street 2:PO BOX 1144
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153
Mailing Address - Country:US
Mailing Address - Phone:540-387-5530
Mailing Address - Fax:540-387-5524
Practice Address - Street 1:105 E. CALHOUN STREET
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-387-5530
Practice Address - Fax:540-387-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8450030Medicaid