Provider First Line Business Practice Location Address: 
WEST VIRGINIA UNIVERSITY SCHOOL OF DENTISTRY
    Provider Second Line Business Practice Location Address: 
ROBERT C. BYRD HEALTH SCIENCES CENTER
    Provider Business Practice Location Address City Name: 
MORGANTOWN
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26506-9495
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-293-2612
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/29/2013