Provider Demographics
NPI:1316202948
Name:WILMINGTON AESTHETIC FACIAL PLASTIC AND RECONSTRUCTIVE CENTER, LLC
Entity Type:Organization
Organization Name:WILMINGTON AESTHETIC FACIAL PLASTIC AND RECONSTRUCTIVE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEIDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-762-1070
Mailing Address - Street 1:1604 PHYSICIANS DR
Mailing Address - Street 2:103
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7362
Mailing Address - Country:US
Mailing Address - Phone:910-762-1070
Mailing Address - Fax:910-762-1083
Practice Address - Street 1:1604 PHYSICIANS DR
Practice Address - Street 2:103
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7362
Practice Address - Country:US
Practice Address - Phone:910-762-1070
Practice Address - Fax:910-762-1083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00621207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty