Provider Demographics
NPI:1467940239
Name:MEAD L. SLAGLE DDS PLLC
Entity Type:Organization
Organization Name:MEAD L. SLAGLE DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-995-4101
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:NC
Mailing Address - Zip Code:27920-0967
Mailing Address - Country:US
Mailing Address - Phone:252-995-4101
Mailing Address - Fax:252-995-4423
Practice Address - Street 1:50716 HWY 12
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:NC
Practice Address - Zip Code:27936-0023
Practice Address - Country:US
Practice Address - Phone:252-995-4101
Practice Address - Fax:252-995-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990057Medicaid
NC90057OtherBLUE CROSS BLUE SHIELD