Provider Demographics
NPI:1366691651
Name:IBAZEBO, DORRETTE JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DORRETTE
Middle Name:JON
Last Name:IBAZEBO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7109 HORSEMAN CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9293
Mailing Address - Country:US
Mailing Address - Phone:336-788-6070
Mailing Address - Fax:
Practice Address - Street 1:6425 OLD PLANK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-3277
Practice Address - Country:US
Practice Address - Phone:336-886-1747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910831Medicaid