Provider Demographics
NPI:1386681625
Name:WILLIAM SUMMERVILLE DDS PLLC
Entity Type:Organization
Organization Name:WILLIAM SUMMERVILLE DDS PLLC
Other - Org Name:DISTINCTIVE DENTISTRY OF CHARLOTTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-540-5400
Mailing Address - Street 1:475 N WENDOVER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1064
Mailing Address - Country:US
Mailing Address - Phone:704-540-5400
Mailing Address - Fax:704-364-5293
Practice Address - Street 1:475 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-540-5400
Practice Address - Fax:704-364-5293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906062Medicaid
NC018X3OtherBCBS OF NCNCHEALTHCHOICE