Basic Information
| Provider Information | |||||||||
| NPI: | 1659536522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ECU PEDIATRIC DENTAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527443520 | ||||||||
| FaxNumber: | 2527443194 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 HERBERT CT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278343736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527443258 | ||||||||
| FaxNumber: | 2527443194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | BENSON | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE DEAN | ||||||||
| AuthorizedOfficialTelephone: | 2527447400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST CAROLINA UNIVERSITY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0066 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223P0300X | 0066 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0221X | 0066 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.