Provider Demographics
NPI:1477649432
Name:EATON, DEREK J (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:J
Last Name:EATON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 SUMMIT CROSSING PL
Mailing Address - Street 2:SUITE 303
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2104
Mailing Address - Country:US
Mailing Address - Phone:704-865-0081
Mailing Address - Fax:704-865-6004
Practice Address - Street 1:660 SUMMIT CROSSING PL
Practice Address - Street 2:SUITE 303
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2104
Practice Address - Country:US
Practice Address - Phone:704-865-0081
Practice Address - Fax:704-865-6004
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40051223P0106X
NC92251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4005Medicaid