Provider Demographics
NPI:1740732361
Name:WEST VIRGINIA UNIVERSITY DENTAL CORPORATION
Entity type:Organization
Organization Name:WEST VIRGINIA UNIVERSITY DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BORGIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-293-1000
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1587
Mailing Address - Country:US
Mailing Address - Phone:304-293-2240
Mailing Address - Fax:304-293-7646
Practice Address - Street 1:1 MED CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-2240
Practice Address - Fax:304-293-7646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9919421Medicare Oscar/Certification