1639353659 NPI number — IREDELL ORAL & FACIAL SURGERY PC

Table of content: (NPI 1639353659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639353659 NPI number — IREDELL ORAL & FACIAL SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IREDELL ORAL & FACIAL SURGERY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639353659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
229 MEDICAL PARK RD
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-8543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-799-0771
Provider Business Mailing Address Fax Number:
704-799-2941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-8543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-799-0771
Provider Business Practice Location Address Fax Number:
704-799-2941
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCARTER
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
704-799-0771

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  9900556 , 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: 891218U , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1218U . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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