Healthcare Provider Details

I. General information

NPI: 1144564634
Provider Name (Legal Business Name): BLUE RIDGE FREE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 US HWY 64 EAST UNIT 12 LAUREL TERRACE
CASHIERS NC
28717
US

IV. Provider business mailing address

PO BOX 451
CASHIERS NC
28717-0451
US

V. Phone/Fax

Practice location:
  • Phone: 828-743-3393
  • Fax: 828-743-5038
Mailing address:
  • Phone: 828-743-3393
  • Fax: 828-743-5038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8147
License Number StateNC

VIII. Authorized Official

Name: MS. KAREN S MINTON
Title or Position: EXECUTIVE DIRECTO
Credential:
Phone: 828-743-3393