MEDICARE: KERVIN MACK DMD MS PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8824	NC

General Provider Information

NPI Number	:	1356688857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KERVIN MACK DMD MS PLLC

Provider Business Mailing Address
First Line	:	1628 MEMORIAL DR STE C
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27215-3596
Country	:	US
Telephone Number	:	336-227-5594
Fax Number	:

Provider Business Practice Location Address
First Line	:	1628 MEMORIAL DR STE C
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27215-3596
Country	:	US
Telephone Number	:	336-227-5594
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KERVIN MACK
Credential	:	DMD, MS
Telephone Number	:	336-227-5594

Provider Enumeration Date	:	01/03/2013
Last Update Date	:	01/03/2013

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