1972940393 NPI number — SHENANDOAH ORAL & MAXILLOFACIAL SURGERY INC

Table of content: DEBORAH LEE BURNHAM PT (NPI 1295866457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972940393 NPI number — SHENANDOAH ORAL & MAXILLOFACIAL SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHENANDOAH ORAL & MAXILLOFACIAL SURGERY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972940393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 GARBER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22602-4386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-667-0100
Provider Business Mailing Address Fax Number:
540-667-0121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 GARBER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22602-4386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-667-0100
Provider Business Practice Location Address Fax Number:
540-667-0121
Provider Enumeration Date:
05/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FUGATE
Authorized Official First Name:
TARA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
703-897-8983

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  0401006414 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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