Basic Information
| Provider Information | |||||||||
| NPI: | 1811192552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPE FEAR AESTHETICS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2814 | ||||||||
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| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287132814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102397600 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Practice Location | |||||||||
| Address1: | 2053 VALLEYGATE DR | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233757 | ||||||||
| FaxNumber: | 9103239247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | DICKERSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | ERNEST | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9103233757 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 2082S0099X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck |
No ID Information.