Provider Demographics
NPI:1568918340
Name:USA DENTAC
Entity Type:Organization
Organization Name:USA DENTAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HSS
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNATOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSD
Authorized Official - Phone:910-643-2196
Mailing Address - Street 1:2817 RIELLY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-643-2196
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7324
Practice Address - Country:US
Practice Address - Phone:910-643-2196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:123456
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7547261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental