Healthcare Provider Details

I. General information

NPI: 1134413248
Provider Name (Legal Business Name): JOHN ADDISON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N SALEM ST STE 105
APEX NC
27502-2315
US

IV. Provider business mailing address

501 N SALEM ST STE 105
APEX NC
27502-2315
US

V. Phone/Fax

Practice location:
  • Phone: 919-804-0351
  • Fax:
Mailing address:
  • Phone: 919-804-0351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN19344
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12513
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: