Basic Information
| Provider Information | |||||||||
| NPI: | 1043423676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VIEW DENTAL TEAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4100 QUARLES CT | ||||||||
| Address2: | |||||||||
| City: | HARRISONBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228018797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404320609 | ||||||||
| FaxNumber: | 5404329097 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 QUARLES CT | ||||||||
| Address2: | |||||||||
| City: | HARRISONBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228018797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404320609 | ||||||||
| FaxNumber: | 5404329097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAVAGE | ||||||||
| AuthorizedOfficialFirstName: | CHELSEA | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5404320609 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 0401006427 | VA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223P0221X | 0401006705 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 010227259 | 05 | VA | MEDICAID |