Provider Demographics
NPI:1235116724
Name:R KELLY FAULK JR DDS PA
Entity Type:Organization
Organization Name:R KELLY FAULK JR DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:FAULK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-774-9419
Mailing Address - Street 1:1806 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330
Mailing Address - Country:US
Mailing Address - Phone:919-774-9419
Mailing Address - Fax:919-774-1404
Practice Address - Street 1:1806 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330
Practice Address - Country:US
Practice Address - Phone:919-774-9419
Practice Address - Fax:919-774-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6030261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8992816Medicaid
NC8992816OtherBCBS