Healthcare Provider Details

I. General information

NPI: 1649783119
Provider Name (Legal Business Name): IDLEWILD FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 INDIAN TRAIL FAIRVIEW RD
INDIAN TRAIL NC
28079-8865
US

IV. Provider business mailing address

4801 INDIAN TRAIL FAIRVIEW RD
INDIAN TRAIL NC
28079-8865
US

V. Phone/Fax

Practice location:
  • Phone: 704-893-0351
  • Fax: 704-893-0354
Mailing address:
  • Phone: 704-893-0351
  • Fax: 704-893-0354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MITESH DHULAB
Title or Position: OWNER
Credential: DMD
Phone: 704-893-0351