Provider Demographics
NPI:1821522970
Name:PURDIE, MYRNA JANAY BRAXTON (DMD)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:JANAY BRAXTON
Last Name:PURDIE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:JANAY
Other - Last Name:BRAXTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2017-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27923724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist