Healthcare Provider Details

I. General information

NPI: 1629760046
Provider Name (Legal Business Name): CHARLENE ENOLPE FICKEY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3847 HENDERSON DR
JACKSONVILLE NC
28546-5228
US

IV. Provider business mailing address

3847 HENDERSON DR
JACKSONVILLE NC
28546-5228
US

V. Phone/Fax

Practice location:
  • Phone: 910-219-4400
  • Fax:
Mailing address:
  • Phone: 910-219-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13218
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: