=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689842163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL G. KOONCE, JR., DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2008
-----------------------------------------------------
Last Update Date | 02/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 SPIVEY RD
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-642-4529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 SPIVEY RD PO BOX 965
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-642-4529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SAMUEL GRADY KOONCE JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 910-642-4529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 4365
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------