Provider Demographics
NPI:1063508208
Name:CARTER, DERRICK GENE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:GENE
Last Name:CARTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2605
Mailing Address - Country:US
Mailing Address - Phone:904-653-3333
Mailing Address - Fax:
Practice Address - Street 1:571 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2605
Practice Address - Country:US
Practice Address - Phone:904-653-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN100041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice