Provider Demographics
NPI:1962626457
Name:JUDKINS, LAFAYETTE SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAFAYETTE
Middle Name:
Last Name:JUDKINS
Suffix:SR
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:PO BOX 1110
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-1110
Mailing Address - Country:US
Mailing Address - Phone:336-342-0474
Mailing Address - Fax:
Practice Address - Street 1:207 TURNER DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5726
Practice Address - Country:US
Practice Address - Phone:336-342-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994751Medicaid
NC1275632366OtherORGANIZATION NPI NUMBER
NC94751OtherBLUE CROSS BLUE SHIELD