Provider Demographics
NPI:1003970534
Name:TYSON, CHESTER J IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:J
Last Name:TYSON
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 IRON GATE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2573
Mailing Address - Country:US
Mailing Address - Phone:910-791-7380
Mailing Address - Fax:910-791-8160
Practice Address - Street 1:2606 IRON GATE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2573
Practice Address - Country:US
Practice Address - Phone:910-791-7380
Practice Address - Fax:910-791-8160
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9003CMedicaid