Healthcare Provider Details

I. General information

NPI: 1710100813
Provider Name (Legal Business Name): GEORGE J STUART JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 ELIZABETH AVE CPCC DEPARTMENT OF DENTAL HYGIENE
CHARLOTTE NC
28204
US

IV. Provider business mailing address

4139 OLDFIELD RD
CHARLOTTE NC
28226
US

V. Phone/Fax

Practice location:
  • Phone: 704-330-6483
  • Fax: 704-330-6477
Mailing address:
  • Phone: 704-542-9420
  • Fax: 704-374-1731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3505
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: