Healthcare Provider Details

I. General information

NPI: 1164874194
Provider Name (Legal Business Name): CALVIN KERR JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ST
FORT BRAGG NC
28310-7324
US

IV. Provider business mailing address

2817 REILLY ST
FORT BRAGG NC
28310-7324
US

V. Phone/Fax

Practice location:
  • Phone: 910-643-2196
  • Fax: 910-907-7904
Mailing address:
  • Phone: 910-643-2196
  • Fax: 910-907-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4298
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: