Healthcare Provider Details

I. General information

NPI: 1316237290
Provider Name (Legal Business Name): KERVIN BRANDON MACK PHARM.D., D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 11/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 MEMORIAL DR #C
BURLINGTON NC
27215-3592
US

IV. Provider business mailing address

1628 MEMORIAL DR #C
BURLINGTON NC
27215-3592
US

V. Phone/Fax

Practice location:
  • Phone: 336-227-5594
  • Fax:
Mailing address:
  • Phone: 336-227-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8824
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: