Provider Demographics
NPI:1659389328
Name:SCULLY, JOHN ROBERT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:SCULLY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ROCKCLIFF PL
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4510
Mailing Address - Country:US
Mailing Address - Phone:828-255-7781
Mailing Address - Fax:828-258-3770
Practice Address - Street 1:5 ROCKCLIFF PL
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4510
Practice Address - Country:US
Practice Address - Phone:828-255-7781
Practice Address - Fax:828-258-3770
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4531OtherNC STATE DENTAL BOARD
NC8997627Medicaid
NC8997627Medicaid
T63827Medicare UPIN