Provider Demographics
NPI:1508976440
Name:ANDERSON AND SLACK PA
Entity Type:Organization
Organization Name:ANDERSON AND SLACK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-353-4242
Mailing Address - Street 1:200 DOCTORS DRIVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-353-4242
Mailing Address - Fax:910-577-6421
Practice Address - Street 1:200 DOCTORS DRIVE
Practice Address - Street 2:SUITE F
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-353-4242
Practice Address - Fax:910-577-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2996OtherDELTA
NC02211OtherBCBS
NC8990244Medicaid
NC02211OtherBCBS