Healthcare Provider Details

I. General information

NPI: 1043191661
Provider Name (Legal Business Name): VALLEYGATE DENTAL SURGERY CENTER OF CHARLOTTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13515 STEELE CREEK RD
CHARLOTTE NC
28273-6839
US

IV. Provider business mailing address

13515 STEELE CREEK RD
CHARLOTTE NC
28273-6839
US

V. Phone/Fax

Practice location:
  • Phone: 910-485-7070
  • Fax: 910-500-6972
Mailing address:
  • Phone: 910-485-7070
  • Fax: 910-500-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER DIGIACOMO
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 910-484-7070