Provider Demographics
NPI:1639304892
Name:KALU, JAYNE EBERECHUKWU (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:EBERECHUKWU
Last Name:KALU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JAYNE
Other - Middle Name:EBERECHUKWU
Other - Last Name:KALU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4995 WEDDINGTON ROAD NW
Mailing Address - Street 2:SUITE 40
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027
Mailing Address - Country:US
Mailing Address - Phone:704-918-5560
Mailing Address - Fax:
Practice Address - Street 1:4995 WEDDINGTON ROAD NW
Practice Address - Street 2:SUITE 40
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027
Practice Address - Country:US
Practice Address - Phone:704-918-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8195122300000X
NC9616122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9616OtherSTATE LICENSE
MADN1855105OtherSTATE DENTAL LICENSE
SC8195OtherSTATE LICENSE
NC9616OtherSTATE LICENSE