Provider Demographics
NPI:1578743597
Name:JERRY S. ALVIS, D.D.S., P.A.
Entity Type:Organization
Organization Name:JERRY S. ALVIS, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:SHUMATE
Authorized Official - Last Name:ALVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-782-5752
Mailing Address - Street 1:5603 DURALEIGH RD
Mailing Address - Street 2:SUITE 131
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2688
Mailing Address - Country:US
Mailing Address - Phone:919-782-5752
Mailing Address - Fax:
Practice Address - Street 1:5603 DURALEIGH RD
Practice Address - Street 2:SUITE 131
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2688
Practice Address - Country:US
Practice Address - Phone:919-782-5752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6792302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC90065OtherBCBS
NCZP0000025Medicaid
1455728OtherUNITED CONCORDIA