Provider Demographics
NPI:1083707475
Name:MCCONVILLE, GLYNDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLYNDA
Middle Name:
Last Name:MCCONVILLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 CARTHAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4162
Mailing Address - Country:US
Mailing Address - Phone:919-718-9188
Mailing Address - Fax:919-718-0900
Practice Address - Street 1:1129 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4162
Practice Address - Country:US
Practice Address - Phone:919-718-9188
Practice Address - Fax:919-718-0900
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901535Medicaid