Provider Demographics
NPI:1417477548
Name:JAMESON, KATLIN POVICH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATLIN
Middle Name:POVICH
Last Name:JAMESON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 EASTWOOD RD STE 105
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-7202
Mailing Address - Country:US
Mailing Address - Phone:910-256-9040
Mailing Address - Fax:
Practice Address - Street 1:2002 EASTWOOD RD STE 105
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7202
Practice Address - Country:US
Practice Address - Phone:910-256-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC107371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice