Provider Demographics
NPI:1619309143
Name:WEBBER DENTISTRY AT SOUTH PARK
Entity Type:Organization
Organization Name:WEBBER DENTISTRY AT SOUTH PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SPURGEON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-247-4030
Mailing Address - Street 1:5940 FAIRVIEW RD
Mailing Address - Street 2:SUITE # 103
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3125
Mailing Address - Country:US
Mailing Address - Phone:704-247-4030
Mailing Address - Fax:
Practice Address - Street 1:5940 FAIRVIEW RD
Practice Address - Street 2:SUITE # 103
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3125
Practice Address - Country:US
Practice Address - Phone:704-247-4030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1265500839OtherINDIVIDUAL NPI
NC101749OtherPROVIDER ID UNITED CONCORDIA