Provider Demographics
NPI:1861643678
Name:ANTHONY R. IMMEDIATA, D.M.D, P.A.
Entity Type:Organization
Organization Name:ANTHONY R. IMMEDIATA, D.M.D, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-846-5500
Mailing Address - Street 1:7101 CREEDMOOR RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-1682
Mailing Address - Country:US
Mailing Address - Phone:919-846-5500
Mailing Address - Fax:919-846-7964
Practice Address - Street 1:7101 CREEDMOOR RD
Practice Address - Street 2:SUITE 109
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1682
Practice Address - Country:US
Practice Address - Phone:919-846-5500
Practice Address - Fax:919-846-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994426Medicaid
NC2340076Medicare PIN