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General NPI Number Information
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NPI Number | 1700238367
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Entity Type | Organization
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Legal Business Name | SOUTHERN LIVING FAMILY DENTISTRY
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Dates
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Enumeration Date | 07/07/2016
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Last Update Date | 08/23/2016
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Provider Practice Location Address
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Address Line | 100 PINECROFT DR
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City | CLAYTON
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State | NC
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Zip | 27520-6923
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Country | US
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Telephone | 919-244-1271
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Fax |
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Provider Business Mailing Address
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Address Line | 100 PINECROFT DR
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City | CLAYTON
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State | NC
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Zip | 27520-6923
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Country | US
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Telephone | 919-244-1271
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Fax |
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | DR. MATTHEW GRABOWSKI
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Credential | D.D.S.
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Telephone | 919-244-1271
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9297
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License Number State | NC
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