Provider Demographics
NPI:1972996197
Name:SOUTHWEST VIRGINIA ORAL & MAXILLOFACIAL SURGERY, PLLC
Entity Type:Organization
Organization Name:SOUTHWEST VIRGINIA ORAL & MAXILLOFACIAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCROGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:540-989-5257
Mailing Address - Street 1:1940 BRAEBURN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7383
Mailing Address - Country:US
Mailing Address - Phone:540-989-5257
Mailing Address - Fax:540-989-5259
Practice Address - Street 1:1940 BRAEBURN DR
Practice Address - Street 2:SUITE A
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7383
Practice Address - Country:US
Practice Address - Phone:540-989-5257
Practice Address - Fax:540-989-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014138111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty