Provider Demographics
NPI:1821360306
Name:COMPREHENSIVE AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:COMPREHENSIVE AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:COVERT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-937-6454
Mailing Address - Street 1:400 DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5291
Mailing Address - Country:US
Mailing Address - Phone:910-937-6454
Mailing Address - Fax:910-937-6453
Practice Address - Street 1:400 DOLPHIN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5291
Practice Address - Country:US
Practice Address - Phone:910-937-6454
Practice Address - Fax:910-937-6453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6662122300000X
NC9795122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991827Medicaid