Provider Demographics
NPI:1902817851
Name:DRS. SCULLY, MATHESON AND FONSECA, P.A.
Entity Type:Organization
Organization Name:DRS. SCULLY, MATHESON AND FONSECA, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SCULLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:828-255-7781
Mailing Address - Street 1:5 ROCKCLIFF PL
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4510
Mailing Address - Country:US
Mailing Address - Phone:828-255-7781
Mailing Address - Fax:828-258-3770
Practice Address - Street 1:5 ROCKCLIFF PL
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4510
Practice Address - Country:US
Practice Address - Phone:828-255-7781
Practice Address - Fax:828-258-3770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2427966Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER