Healthcare Provider Details

I. General information

NPI: 1952889263
Provider Name (Legal Business Name): JAMAL BAJWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2325
US

IV. Provider business mailing address

3711 OLYMPIA DR
RALEIGH NC
27603-3460
US

V. Phone/Fax

Practice location:
  • Phone: 919-956-4000
  • Fax:
Mailing address:
  • Phone: 336-588-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015731
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12167
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: