Provider Demographics
NPI:1972218162
Name:DR. CAMERON & ASSOCIATES OF ROLESVILLE, PLLC
Entity Type:Organization
Organization Name:DR. CAMERON & ASSOCIATES OF ROLESVILLE, PLLC
Other - Org Name:GLADWELL ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-550-5440
Mailing Address - Street 1:PO BOX 603775
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 REDFORD PLACE DR STE 200
Practice Address - Street 2:
Practice Address - City:ROLESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27571-9545
Practice Address - Country:US
Practice Address - Phone:919-977-0627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972790293OtherNPI
1710290614OtherNPI
1578858015OtherNPI