=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801965637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUGLAS R. TERRY D.D.S., PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 MULBERRY ST SW
-----------------------------------------------------
City | LENOIR
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28645-5725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-758-1906
-----------------------------------------------------
Fax | 828-758-1989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 MULBERRY ST SW
-----------------------------------------------------
City | LENOIR
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28645-5725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-758-1906
-----------------------------------------------------
Fax | 828-758-1989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. DOUGLAS ROGER TERRY II
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 828-758-1906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6278
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------