Provider Demographics
NPI:1104936616
Name:SUTHERLAND, WILLIAM MCIVOR (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MCIVOR
Last Name:SUTHERLAND
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 460
Mailing Address - Street 2:4312 S. AMHERST HIGHWAY
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-0460
Mailing Address - Country:US
Mailing Address - Phone:434-847-0171
Mailing Address - Fax:
Practice Address - Street 1:4312 S. AMHERST HIGHWAY
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572-0460
Practice Address - Country:US
Practice Address - Phone:434-847-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010059741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice