Healthcare Provider Details

I. General information

NPI: 1063415032
Provider Name (Legal Business Name): PARK CEDAR DENTISTRY PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10027 PARK CEDAR DR STE 100
CHARLOTTE NC
28210-8903
US

IV. Provider business mailing address

10027 PARK CEDAR DR STE 100
CHARLOTTE NC
28210-8903
US

V. Phone/Fax

Practice location:
  • Phone: 704-752-0500
  • Fax: 704-752-0502
Mailing address:
  • Phone: 704-752-0500
  • Fax: 704-752-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9488
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7809
License Number StateNC

VIII. Authorized Official

Name: DR. SUMMER L CALDWELL
Title or Position: PARTNER
Credential: DDS
Phone: 704-752-0500