Provider Demographics
NPI:1962706754
Name:STRAIGHT SMILES OF ROANOKE, PLLC
Entity type:Organization
Organization Name:STRAIGHT SMILES OF ROANOKE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0343
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:1502 WILLIAMSON RD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-5130
Practice Address - Country:US
Practice Address - Phone:540-206-2203
Practice Address - Fax:540-400-0525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA208806Medicaid