Healthcare Provider Details

I. General information

NPI: 1386131993
Provider Name (Legal Business Name): NYKIA LATASHA MCNEIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 BREWER ST
ASHEBORO NC
27203-4896
US

IV. Provider business mailing address

517 PENRY RD
GREENSBORO NC
27405-6525
US

V. Phone/Fax

Practice location:
  • Phone: 336-610-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: