Healthcare Provider Details

I. General information

NPI: 1851643167
Provider Name (Legal Business Name): VAN WALLACE MCCARLIE JR. M.A., D.M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 MACGREGOR DOWNS RD ROSS HALL, ROOM 3151
GREENVILLE NC
27834-5925
US

IV. Provider business mailing address

1851 MACGREGOR DOWNS RD ROSS HALL, ROOM 3151
GREENVILLE NC
27834-5925
US

V. Phone/Fax

Practice location:
  • Phone: 252-737-7168
  • Fax: 252-737-7080
Mailing address:
  • Phone: 252-737-7168
  • Fax: 252-737-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0118
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: