Provider Demographics
NPI:1912346073
Name:LADYSMITH DENTAL CENTER
Entity Type:Organization
Organization Name:LADYSMITH DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROTHENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-589-1491
Mailing Address - Street 1:18010 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-2922
Mailing Address - Country:US
Mailing Address - Phone:804-589-1491
Mailing Address - Fax:804-589-1494
Practice Address - Street 1:18010 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-2922
Practice Address - Country:US
Practice Address - Phone:804-589-1491
Practice Address - Fax:804-589-1494
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LADYSMITH DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412257122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty