Provider Demographics
NPI:1497001127
Name:EAST CAROLINA UNIVERSITY SCHOOL OF DENTAL MEDICINE
Entity Type:Organization
Organization Name:EAST CAROLINA UNIVERSITY SCHOOL OF DENTAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, COMMUNITY DENTAL PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCHOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:252-737-7029
Mailing Address - Street 1:1161 N ROAD STREET
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-737-7029
Mailing Address - Fax:252-737-7049
Practice Address - Street 1:1161 N ROAD STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-737-7029
Practice Address - Fax:252-737-7049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC9053261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919862Medicaid