Provider Demographics
NPI:1871881912
Name:ABINGDON PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:ABINGDON PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROLON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:276-739-7942
Mailing Address - Street 1:PO BOX 1925
Mailing Address - Street 2:465 W. MAIN STREET
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-1925
Mailing Address - Country:US
Mailing Address - Phone:276-739-7942
Mailing Address - Fax:276-739-7943
Practice Address - Street 1:465 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2630
Practice Address - Country:US
Practice Address - Phone:276-739-7942
Practice Address - Fax:276-739-7943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014109011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty