Healthcare Provider Details

I. General information

NPI: 1134184096
Provider Name (Legal Business Name): JOHN DAVID CIVILS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 MAGNOLIA ST
GREENSBORO NC
27401
US

IV. Provider business mailing address

PO BOX 13646
GREENSBORO NC
27415
US

V. Phone/Fax

Practice location:
  • Phone: 336-272-4177
  • Fax: 336-272-6313
Mailing address:
  • Phone: 336-272-4177
  • Fax: 336-272-6313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7218
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: