Healthcare Provider Details

I. General information

NPI: 1033108980
Provider Name (Legal Business Name): JAMES KENNETH DZIADZIOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 AMALIA ST NE
CONCORD NC
28025-2434
US

IV. Provider business mailing address

645 AMALIA ST NE STE 1
CONCORD NC
28025-2434
US

V. Phone/Fax

Practice location:
  • Phone: 704-295-3255
  • Fax:
Mailing address:
  • Phone: 704-295-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number9700538
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: