Healthcare Provider Details

I. General information

NPI: 1790757649
Provider Name (Legal Business Name): DIEDRA S. MCGUIRE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2006
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WIDEWATERS PKWY
KNIGHTDALE NC
27545-6102
US

IV. Provider business mailing address

1036 PRAIRIE ASTER CT
WAKE FOREST NC
27587-6169
US

V. Phone/Fax

Practice location:
  • Phone: 919-266-6999
  • Fax:
Mailing address:
  • Phone: 914-419-3298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11683
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: