Provider Demographics
NPI:1447309836
Name:BROWN, BOBBY L (DDS)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:L
Last Name:BROWN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2045
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-2045
Mailing Address - Country:US
Mailing Address - Phone:276-628-9507
Mailing Address - Fax:276-628-9439
Practice Address - Street 1:915 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210
Practice Address - Country:US
Practice Address - Phone:276-628-9507
Practice Address - Fax:276-628-9439
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9181261Medicaid
635119OtherUNITED CONCORDIA
VA034913OtherANTHEM