Provider Demographics
NPI:1396720686
Name:POWELL, L VIRGINIA (DMD)
Entity type:Individual
Prefix:DR
First Name:L
Middle Name:VIRGINIA
Last Name:POWELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5736
Mailing Address - Country:US
Mailing Address - Phone:707-462-1540
Mailing Address - Fax:707-462-7601
Practice Address - Street 1:1091 S DORA ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5736
Practice Address - Country:US
Practice Address - Phone:707-462-1540
Practice Address - Fax:707-462-7601
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice