Provider Demographics
NPI:1417922329
Name:DEXTER, MARY JO (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:
Last Name:DEXTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WHIT CT
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-5825
Mailing Address - Country:US
Mailing Address - Phone:919-567-1777
Mailing Address - Fax:919-567-9349
Practice Address - Street 1:102 WHIT CT
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-5825
Practice Address - Country:US
Practice Address - Phone:919-567-1777
Practice Address - Fax:919-567-9349
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890921BMedicaid
NC0921BOtherBCBS
NC890921BMedicaid
NCU18662Medicare UPIN