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General NPI Number Information
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NPI Number | 1669240586
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Entity Type | Organization
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Legal Business Name | CAROLINA PEDIATRIC DENTAL MANAGEMENT, LLC
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Dates
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Enumeration Date | 12/20/2023
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Last Update Date | 12/20/2023
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Provider Practice Location Address
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Address Line | 3000 NEW BERN AVE
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City | RALEIGH
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State | NC
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Zip | 27610-1231
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Country | US
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Telephone | 919-570-0180
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Fax |
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Provider Business Mailing Address
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Address Line | 13580 GROUPE DR STE 305
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City | WOODBRIDGE
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State | VA
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Zip | 22192-4165
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | AMENA HOLLEY
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Credential |
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Telephone | 248-550-5440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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