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General NPI Number Information
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NPI Number | 1801939699
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY AND ORTHODONTICS
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 1146 N NEW HOPE RD
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City | GASTONIA
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State | NC
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Zip | 28054-2959
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Country | US
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Telephone | 704-865-6425
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Fax |
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Provider Business Mailing Address
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Address Line | 1146 N NEW HOPE RD
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City | GASTONIA
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State | NC
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Zip | 28054-2959
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Country | US
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Telephone | 704-865-6425
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. CHARLES W CONNOR JR.
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Credential | DDS
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Telephone | 704-865-6425
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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 | 4623
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License Number State | NC
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