Basic Information
| Provider Information | |||||||||
| NPI: | 1568918340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | USA DENTAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2817 RIELLY ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | BERNATOVITZ | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | HSS | ||||||||
| AuthorizedOfficialTelephone: | 9106432196 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 123456 | ||||||||
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| AuthorizedOfficialCredential: | BSD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 7547 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.