Provider Demographics
NPI:1790212462
Name:EAST CAROLINA UNIVERSITY SCHOOL OF DENTAL MEDICINE
Entity Type:Organization
Organization Name:EAST CAROLINA UNIVERSITY SCHOOL OF DENTAL MEDICINE
Other - Org Name:ECU SCHOOL OF DENTAL MEDICINE-FPC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-737-7011
Mailing Address - Street 1:1851 MACGREGOR DOWNS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:252-737-7011
Mailing Address - Fax:252-737-7846
Practice Address - Street 1:1851 MACGREGOR DOWNS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5925
Practice Address - Country:US
Practice Address - Phone:252-737-7011
Practice Address - Fax:252-737-7846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST CAROLINA UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
No125Q00000XDental ProvidersOral MedicinistGroup - Multi-Specialty