Provider Demographics
NPI:1073069555
Name:EAST CAROLINA UNIVERSITY SCHOOL OF DENTAL MEDICINE
Entity Type:Organization
Organization Name:EAST CAROLINA UNIVERSITY SCHOOL OF DENTAL MEDICINE
Other - Org Name:ECU SCHOOL OF DENTAL MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:DEAN, SCHOOL OF DENTAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:DEXTER
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:CHADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:252-737-7401
Mailing Address - Street 1:1851 MACGREGOR DOWNS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5925
Mailing Address - Country:US
Mailing Address - Phone:252-737-7000
Mailing Address - Fax:252-737-7049
Practice Address - Street 1:316 COUNTY SERVICES PARK
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5713
Practice Address - Country:US
Practice Address - Phone:828-586-1200
Practice Address - Fax:828-586-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920268Medicaid