Provider Demographics
NPI:1326226796
Name:UNIVERSITY DENTAL ASSOCIATES CLEMMONS
Entity Type:Organization
Organization Name:UNIVERSITY DENTAL ASSOCIATES CLEMMONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DATA BASE ADMI
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-549-1509
Mailing Address - Street 1:6201 TOWNCENTER DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9383
Mailing Address - Country:US
Mailing Address - Phone:704-549-1509
Mailing Address - Fax:
Practice Address - Street 1:6201 TOWNCENTER DR
Practice Address - Street 2:SUITE 130
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9383
Practice Address - Country:US
Practice Address - Phone:704-549-1509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty