Healthcare Provider Details

I. General information

NPI: 1245682715
Provider Name (Legal Business Name): USA DENTAC HQS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
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:
Mailing address:
  • Phone: 910-643-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1486
License Number StateNC

VIII. Authorized Official

Name: CHARLES BERNATOVITZ
Title or Position: HSS
Credential: BSD
Phone: 910-643-2196