Provider Demographics
NPI:1952477440
Name:JIAMACHELLO, PHILIP FREDERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:FREDERIC
Last Name:JIAMACHELLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 SIMPSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4299
Mailing Address - Country:US
Mailing Address - Phone:704-484-3366
Mailing Address - Fax:704-484-3441
Practice Address - Street 1:221 SIMPSON PARK RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4299
Practice Address - Country:US
Practice Address - Phone:704-484-3366
Practice Address - Fax:704-484-3441
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89994612Medicaid
NCU28992Medicare UPIN