Healthcare Provider Details

I. General information

NPI: 1568693877
Provider Name (Legal Business Name): JEFFREY E AYCOCK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MILLER ST
WINSTON SALEM NC
27103-2508
US

IV. Provider business mailing address

600 MCKENZIE CIR
SOUTHPORT NC
28461-5192
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-8200
  • Fax:
Mailing address:
  • Phone: 985-226-7667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11191
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: