Healthcare Provider Details

I. General information

NPI: 1659536522
Provider Name (Legal Business Name): ECU PEDIATRIC DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 HERBERT CT
GREENVILLE NC
27834-3736
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-3258
  • Fax: 252-744-3194
Mailing address:
  • Phone: 252-744-3520
  • Fax: 252-744-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0066
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0066
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0066
License Number StateNC

VIII. Authorized Official

Name: DR. NICHOLAS BENSON
Title or Position: VICE DEAN
Credential: M.D.
Phone: 252-744-7400