Provider Demographics
NPI:1972940393
Name:SHENANDOAH ORAL & MAXILLOFACIAL SURGERY INC
Entity Type:Organization
Organization Name:SHENANDOAH ORAL & MAXILLOFACIAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FUGATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-897-8983
Mailing Address - Street 1:170 GARBER LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-4386
Mailing Address - Country:US
Mailing Address - Phone:540-667-0100
Mailing Address - Fax:540-667-0121
Practice Address - Street 1:170 GARBER LN
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-4386
Practice Address - Country:US
Practice Address - Phone:540-667-0100
Practice Address - Fax:540-667-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-24
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010064141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty