Provider Demographics
NPI:1154439297
Name:JAMISON, PHILIP LEDFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LEDFORD
Last Name:JAMISON
Suffix:
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 1:571 COX RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0632
Mailing Address - Country:US
Mailing Address - Phone:704-865-7603
Mailing Address - Fax:704-865-6411
Practice Address - Street 1:571 COX RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0632
Practice Address - Country:US
Practice Address - Phone:704-865-7603
Practice Address - Fax:704-865-6411
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994489Medicaid
NC94489OtherBCBS PROVIDER NUMBER
NC2428552Medicare ID - Type UnspecifiedMEDICARE
NC8994489Medicaid