Provider Demographics
NPI:1821127051
Name:MARY JO DEXTER,OD,PA
Entity Type:Organization
Organization Name:MARY JO DEXTER,OD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:DEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-567-1777
Mailing Address - Street 1:102 WHIT CT
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-5825
Mailing Address - Country:US
Mailing Address - Phone:919-567-1777
Mailing Address - Fax:919-567-9349
Practice Address - Street 1:102 WHIT CT
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-5825
Practice Address - Country:US
Practice Address - Phone:919-567-1777
Practice Address - Fax:919-567-9349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890921BMedicaid
NC0921BOtherBCBS
NC=========OtherTAX ID
NCU18662Medicare UPIN
NC890921BMedicaid