1639304892 NPI number — DR. JAYNE EBERECHUKWU KALU DMD

Table of content: DR. JAYNE EBERECHUKWU KALU DMD (NPI 1639304892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639304892 NPI number — DR. JAYNE EBERECHUKWU KALU DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALU
Provider First Name:
JAYNE
Provider Middle Name:
EBERECHUKWU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KALU
Provider Other First Name:
JAYNE
Provider Other Middle Name:
EBERECHUKWU
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639304892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4995 WEDDINGTON ROAD NW
Provider Second Line Business Mailing Address:
SUITE 40
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-918-5560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4995 WEDDINGTON ROAD NW
Provider Second Line Business Practice Location Address:
SUITE 40
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-918-5560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  8195 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 9616 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9616 . This is a "STATE LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DN1855105 . This is a "STATE DENTAL LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 8195 . This is a "STATE LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".