Healthcare Provider Details

I. General information

NPI: 1568750503
Provider Name (Legal Business Name): PORT CITY FAMILY AND COSMETIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 PRINCESS ST
WILMINGTON NC
28401-3848
US

IV. Provider business mailing address

1624 PRINCESS ST
WILMINGTON NC
28401-3848
US

V. Phone/Fax

Practice location:
  • Phone: 910-251-8174
  • Fax: 910-341-3037
Mailing address:
  • Phone: 910-251-8174
  • Fax: 910-341-3037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JILLIAN BARRAS
Title or Position: OWNER
Credential: DDS
Phone: 910-251-8174