Provider Demographics
NPI:1689842163
Name:SAMUEL G. KOONCE, JR., DDS, PA
Entity Type:Organization
Organization Name:SAMUEL G. KOONCE, JR., DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:GRADY
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-642-4529
Mailing Address - Street 1:900 SPIVEY RD
Mailing Address - Street 2:PO BOX 965
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-2915
Mailing Address - Country:US
Mailing Address - Phone:910-642-4529
Mailing Address - Fax:
Practice Address - Street 1:900 SPIVEY RD
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2915
Practice Address - Country:US
Practice Address - Phone:910-642-4529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4365261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995053Medicaid