=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558537399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J TRAHEY MANER DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 05/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2518 S CROATAN HWY STE C
-----------------------------------------------------
City | NAGS HEAD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27959-8994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-441-1006
-----------------------------------------------------
Fax | 252-441-9488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2518 S CROATAN HWY STE C
-----------------------------------------------------
City | NAGS HEAD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27959-8994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-441-1006
-----------------------------------------------------
Fax | 252-441-9488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | JAMES TRAHEY MANER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-441-1006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 7304
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------