Healthcare Provider Details

I. General information

NPI: 1407355704
Provider Name (Legal Business Name): TRIAD PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 10/29/2021
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4012 MENDENHALL OAKS PKWY
HIGH POINT NC
27265-8076
US

IV. Provider business mailing address

4148 MENDENHALL OAKS PKWY
HIGH POINT NC
27265-8034
US

V. Phone/Fax

Practice location:
  • Phone: 336-822-9671
  • Fax: 336-882-2824
Mailing address:
  • Phone: 336-822-9671
  • Fax: 336-882-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007-00476
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. THOMAS WAYNE DILLARD
Title or Position: OWNER
Credential: MD
Phone: 336-822-9671