Healthcare Provider Details

I. General information

NPI: 1811192552
Provider Name (Legal Business Name): CAPE FEAR AESTHETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 VALLEYGATE DR STE. 102
FAYETTEVILLE NC
28304-3688
US

IV. Provider business mailing address

PO BOX 2814
BRYSON CITY NC
28713-2814
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-3757
  • Fax: 910-323-9247
Mailing address:
  • Phone: 910-239-7600
  • Fax: 828-538-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: EDWARD ERNEST DICKERSON IV
Title or Position: OWNER
Credential: MD
Phone: 910-323-3757