Healthcare Provider Details

I. General information

NPI: 1326576398
Provider Name (Legal Business Name): CORY CRAVEN JAMESON II DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S BAXTER DR
LELAND NC
28451-0139
US

IV. Provider business mailing address

2001 S BAXTER DR
LELAND NC
28451-0139
US

V. Phone/Fax

Practice location:
  • Phone: 527-226-8152
  • Fax:
Mailing address:
  • Phone: 527-226-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10836
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: