=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356688857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KERVIN MACK DMD MS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2013
-----------------------------------------------------
Last Update Date | 01/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1628 MEMORIAL DR STE C
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-3596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-227-5594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1628 MEMORIAL DR STE C
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-3596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-227-5594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KERVIN MACK
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 336-227-5594
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 8824
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------