Provider Demographics
NPI:1447010616
Name:WAYESBORO BLUE RIDGE DENTAL PLC
Entity type:Organization
Organization Name:WAYESBORO BLUE RIDGE DENTAL PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-997-8878
Mailing Address - Street 1:19810 W CATAWBA AVE # A1
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-6523
Practice Address - Country:US
Practice Address - Phone:540-943-5202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty