=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629730130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATESVILLE AMY KINLAW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2021
-----------------------------------------------------
Last Update Date | 10/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1316 DAVIE AVE STE C
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677-3561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-635-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 167 1ST AVE SW
-----------------------------------------------------
City | TAYLORSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28681-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-635-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL MANAGER
-----------------------------------------------------
Name | KAROL MANCHOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-635-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------