Provider Demographics
NPI:1275632366
Name:LAFAYETTE JUDKINS DDS PA
Entity Type:Organization
Organization Name:LAFAYETTE JUDKINS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAFAYETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDKINS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-342-0474
Mailing Address - Street 1:PO BOX 1110
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-1110
Mailing Address - Country:US
Mailing Address - Phone:336-342-0474
Mailing Address - Fax:336-342-7684
Practice Address - Street 1:207 TURNER DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5726
Practice Address - Country:US
Practice Address - Phone:336-342-0474
Practice Address - Fax:336-342-7684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC47811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC94751OtherHEALTH CHOICE
NC8994751Medicaid