Provider Demographics
NPI:1194212456
Name:BRIAN L MAYNOR D.D.S., PLLC
Entity Type:Organization
Organization Name:BRIAN L MAYNOR D.D.S., PLLC
Other - Org Name:CROSSCREEK FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LANIER
Authorized Official - Last Name:MAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-533-9300
Mailing Address - Street 1:523 NC HIGHWAY 125
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-6447
Mailing Address - Country:US
Mailing Address - Phone:252-533-9300
Mailing Address - Fax:
Practice Address - Street 1:523 NC HIGHWAY 125
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-6447
Practice Address - Country:US
Practice Address - Phone:252-533-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-21
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty