Healthcare Provider Details

I. General information

NPI: 1982672929
Provider Name (Legal Business Name): DAVID MANDALINICH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 PEMBROKE RD
GREENSBORO NC
27408-7901
US

IV. Provider business mailing address

1817 PEMBROKE RD
GREENSBORO NC
27408-7901
US

V. Phone/Fax

Practice location:
  • Phone: 336-275-6144
  • Fax: 336-373-0119
Mailing address:
  • Phone: 336-275-6144
  • Fax: 336-373-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5312
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: