Provider Demographics
NPI:1992297733
Name:MORGANTOWN DENTAL, PLLC
Entity type:Organization
Organization Name:MORGANTOWN DENTAL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-765-5019
Mailing Address - Street 1:9000 COOMBS FARM DR
Mailing Address - Street 2:STE 304
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508
Mailing Address - Country:US
Mailing Address - Phone:304-594-1670
Mailing Address - Fax:304-594-1671
Practice Address - Street 1:9000 COOMBS FARM DR
Practice Address - Street 2:STE 304
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:304-594-1670
Practice Address - Fax:304-594-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34561223E0200X
WV36821223E0200X
WV38151223E0200X
WV40921223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty