MEDICARE: DEST,GARDEN, HENDRICK & KINGSBURY, DDS, 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	1223G0001X	General Practice Dentistry	6764	NC
2	1223G0001X	General Practice Dentistry	8726	NC
3	1223G0001X	General Practice Dentistry	6442	NC
4	1223G0001X	General Practice Dentistry	5283	NC

General Provider Information

NPI Number	:	1841523487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEST,GARDEN, HENDRICK & KINGSBURY, DDS, PLLC

Provider Business Mailing Address
First Line	:	403 S CENTRAL AVE
Second Line	:
City	:	LOCUST
State	:	NC
Zip	:	28097-7142
Country	:	US
Telephone Number	:	704-547-1279
Fax Number	:	704-547-8383

Provider Business Practice Location Address
First Line	:	8305 UNIVERSITY EXEC PARK DR STE 300
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-3357
Country	:	US
Telephone Number	:	704-547-1279
Fax Number	:	704-547-8383

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	RICHARD F DEST
Credential	:	DDS
Telephone Number	:	704-737-3133

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	09/15/2009

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