Healthcare Provider Details

I. General information

NPI: 1194838961
Provider Name (Legal Business Name): JAMES ANTHONY VACCA DDS M SR O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 DAVIE AVE
STATESVILLE NC
28677
US

IV. Provider business mailing address

1316 DAVIE AVE
STATESVILLE NC
28677
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-0969
  • Fax: 704-872-0960
Mailing address:
  • Phone: 704-892-0969
  • Fax: 704-872-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3727
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: