Basic Information
| Provider Information | |||||||||
| NPI: | 1609392034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINNEY | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 CASSELL DR APT 204 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283111606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243169563 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAL ACTIVITY, ATTN: MCDS NA B | ||||||||
| Address2: | BLDG 6837 NORMANDY DRIVE | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | 9103967017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2017 | ||||||||
| LastUpdateDate: | 08/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS041295 | PA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | DS041295 | 01 | PA | DENTAL LICENSE | OTHER |