Healthcare Provider Details

I. General information

NPI: 1881761583
Provider Name (Legal Business Name): THE CENTER FOR FUNCTIONAL & AESTHETIC FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 FORTUNES RIDGE DR SUITE G
DURHAM NC
27713-6102
US

IV. Provider business mailing address

5501 FORTUNES RIDGE DR SUITE G
DURHAM NC
27713-6102
US

V. Phone/Fax

Practice location:
  • Phone: 919-419-9222
  • Fax: 919-419-9255
Mailing address:
  • Phone: 919-419-9222
  • Fax: 919-419-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9900887
License Number StateNC

VIII. Authorized Official

Name: MRS. JENNIFER THOMAS PICKETT
Title or Position: PATIENT CARE COORDINATOR
Credential:
Phone: 919-419-9222