=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548976897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS. ABDELBAKY, BOES, CAMERON & ASSOCIATES OF ROLESVILLE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 REDFORD PLACE DRIVE SUITE 300
-----------------------------------------------------
City | ROLESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-931-8626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 603763
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | AMENA HOLLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-550-5440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------