MEDICARE: RICHARD WETHERILL III D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6892	NC

General Provider Information

NPI Number	:	1316053176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD WETHERILL III D.D.S.

Provider Business Mailing Address
First Line	:	1209 FLORAL PKWY
Second Line	:	SUITE A
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6216
Country	:	US
Telephone Number	:	910-792-1085
Fax Number	:	910-792-6184

Provider Business Practice Location Address
First Line	:	1209 FLORAL PKWY
Second Line	:	SUITE A
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6216
Country	:	US
Telephone Number	:	910-792-1085
Fax Number	:	910-792-6184

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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