Provider Demographics
NPI:1114095247
Name:EALY, ROBERT DALE JR (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
Last Name:EALY
Suffix:JR
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 1:300 ENOLA RD
Mailing Address - Street 2:J IVERSON RIDDLE DEVELOPMENTAL CENTER/DHHS/NC
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4608
Mailing Address - Country:US
Mailing Address - Phone:828-433-2639
Mailing Address - Fax:828-433-2694
Practice Address - Street 1:300 ENOLA RD
Practice Address - Street 2:J IVERSON RIDDLE DEVELOPMENTAL CENTER/DHHS/NC
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4608
Practice Address - Country:US
Practice Address - Phone:828-433-2639
Practice Address - Fax:828-433-2694
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50771223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8992282Medicaid
U39046Medicare UPIN