Provider Demographics
NPI:1629025564
Name:S C TOLBERT DDS PA
Entity Type:Organization
Organization Name:S C TOLBERT DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:S C
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:D D S P A
Authorized Official - Phone:910-484-6116
Mailing Address - Street 1:3419 C MELROSE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304
Mailing Address - Country:US
Mailing Address - Phone:910-484-6116
Mailing Address - Fax:910-484-5950
Practice Address - Street 1:3419 C MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:910-484-6116
Practice Address - Fax:910-484-5950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015V5OtherBCBS GROUP
NC811969OtherUNITED CONCORDIA
NC015V5OtherBCBS GROUP
NCT63780Medicare UPIN