Provider Demographics
NPI:1235200106
Name:NEWSOME, MICHAEL BENJAMIN (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:NEWSOME
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:PO BOX 350
Mailing Address - Street 2:701 N MAIN ST PERSON FAMILY DENTAL CENTER
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573
Mailing Address - Country:US
Mailing Address - Phone:336-599-9271
Mailing Address - Fax:336-330-0247
Practice Address - Street 1:701 N MAIN ST
Practice Address - Street 2:PERSON FAMILY DENTAL CENTER
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573
Practice Address - Country:US
Practice Address - Phone:336-599-9271
Practice Address - Fax:336-330-0247
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7644NC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902RGMedicaid