Healthcare Provider Details

I. General information

NPI: 1154627230
Provider Name (Legal Business Name): JACK T WINCHESTER DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 SYMI CIR
MOREHEAD CITY NC
28557-4314
US

IV. Provider business mailing address

3705 SYMI CIR
MOREHEAD CITY NC
28557-4314
US

V. Phone/Fax

Practice location:
  • Phone: 252-247-3510
  • Fax: 252-247-6197
Mailing address:
  • Phone: 252-247-3510
  • Fax: 252-247-6197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5372
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number5372
License Number StateNC

VIII. Authorized Official

Name: JACK TYLER WINCHESTER
Title or Position: OWNER
Credential: DMD
Phone: 252-247-3510