Healthcare Provider Details

I. General information

NPI: 1063100691
Provider Name (Legal Business Name): CODY CLINTON PHEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 CINEMA DR
WILMINGTON NC
28403-1490
US

IV. Provider business mailing address

126 CINEMA DR
WILMINGTON NC
28403-1490
US

V. Phone/Fax

Practice location:
  • Phone: 910-940-0259
  • Fax:
Mailing address:
  • Phone: 910-940-0259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13237
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: