Provider Demographics
NPI:1639456486
Name:DEREK J EATON DDS PLLC
Entity Type:Organization
Organization Name:DEREK J EATON DDS PLLC
Other - Org Name:CAROLINA ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-865-0081
Mailing Address - Street 1:660 SUMMIT CROSSING PL
Mailing Address - Street 2:SUITE 303
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2104
Mailing Address - Country:US
Mailing Address - Phone:704-865-0081
Mailing Address - Fax:704-865-6004
Practice Address - Street 1:660 SUMMIT CROSSING PL
Practice Address - Street 2:SUITE 303
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2104
Practice Address - Country:US
Practice Address - Phone:704-865-0081
Practice Address - Fax:704-865-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9225261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery