=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811192552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPE FEAR AESTHETICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 07/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2053 VALLEYGATE DR STE. 102
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-3757
-----------------------------------------------------
Fax | 910-323-9247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2814
-----------------------------------------------------
City | BRYSON CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28713-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-239-7600
-----------------------------------------------------
Fax | 828-538-4441
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EDWARD ERNEST DICKERSON IV
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-323-3757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2082S0099X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------