Healthcare Provider Details

I. General information

NPI: 1376641233
Provider Name (Legal Business Name): JACK C CASE JR. DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 RANDOLPH RD SUITE 600
CHARLOTTE NC
28207-2034
US

IV. Provider business mailing address

2711 RANDOLPH RD SUITE 600
CHARLOTTE NC
28207-2034
US

V. Phone/Fax

Practice location:
  • Phone: 704-334-7202
  • Fax: 704-372-2690
Mailing address:
  • Phone: 704-334-7202
  • Fax: 704-372-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number200001224634
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: