Provider Demographics
NPI:1558345983
Name:MARTIN TYRRELL WASHINGTON DISTRICT HEALTH DEPT
Entity Type:Organization
Organization Name:MARTIN TYRRELL WASHINGTON DISTRICT HEALTH DEPT
Other - Org Name:MARTIN TYRRELL WASHINGTON DISTRICT DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT II
Authorized Official - Prefix:
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-793-3023
Mailing Address - Street 1:198 NC HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NC
Mailing Address - Zip Code:27962-9232
Mailing Address - Country:US
Mailing Address - Phone:252-793-3023
Mailing Address - Fax:252-791-3159
Practice Address - Street 1:198 NC HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962-9232
Practice Address - Country:US
Practice Address - Phone:252-793-3023
Practice Address - Fax:252-791-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404410Medicaid
NC07059OtherBLUE CROSS
NC=========OtherCOMMERCIAL