Provider Demographics
NPI:1366600850
Name:SHORT CLINE, MISTY M (DDS)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:M
Last Name:SHORT CLINE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MISTY
Other - Middle Name:M
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:517 TAZEWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-1724
Mailing Address - Country:US
Mailing Address - Phone:276-322-7568
Mailing Address - Fax:276-322-7269
Practice Address - Street 1:517 TAZEWELL AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-1724
Practice Address - Country:US
Practice Address - Phone:276-322-7568
Practice Address - Fax:276-322-7269
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38161223G0001X
VA0401412415122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810012047Medicaid
VA1366600850Medicaid