Provider Demographics
NPI:1962496299
Name:LONDON, PATRICIA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
Last Name:LONDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CHURCH ST NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-4763
Mailing Address - Country:US
Mailing Address - Phone:704-782-1012
Mailing Address - Fax:704-782-1368
Practice Address - Street 1:213 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4763
Practice Address - Country:US
Practice Address - Phone:704-782-1012
Practice Address - Fax:704-782-1368
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
NC50571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997786Medicaid
NC97786OtherBLUE CROSS BLUE SHIELD
NC8997786Medicaid