MEDICARE: DR. JERRY WAYNE CHILDRESS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3658	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	91555	OTHER		BCBS

General Provider Information

NPI Number	:	1528132859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY WAYNE CHILDRESS DDS

Provider Business Mailing Address
First Line	:	6708 REGAL OAKS DRIVE
Second Line	:	REGAL OAKS DENTAL OFFICE
City	:	CHARLOTTE
State	:	NC
Zip	:	28212
Country	:	US
Telephone Number	:	704-536-0269
Fax Number	:	704-536-7520

Provider Business Practice Location Address
First Line	:	6708 REGAL OAKS DRIVE
Second Line	:	REGAL OAKS DENTAL OFFICE
City	:	CHARLOTTE
State	:	NC
Zip	:	28212
Country	:	US
Telephone Number	:	704-536-0269
Fax Number	:	704-536-7520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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