Healthcare Provider Details

I. General information

NPI: 1861643678
Provider Name (Legal Business Name): ANTHONY R. IMMEDIATA, D.M.D, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 CREEDMOOR RD SUITE 109
RALEIGH NC
27613-1682
US

IV. Provider business mailing address

7101 CREEDMOOR RD SUITE 109
RALEIGH NC
27613-1682
US

V. Phone/Fax

Practice location:
  • Phone: 919-846-5500
  • Fax: 919-846-7964
Mailing address:
  • Phone: 919-846-5500
  • Fax: 919-846-7964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5022
License Number StateNC

VIII. Authorized Official

Name: MS. BARBARA SED
Title or Position: OFFICE MANAGER
Credential:
Phone: 919-846-5500