Provider Demographics
NPI:1013164185
Name:GLYNDA R. MCCONVILLE, DDS, PA
Entity Type:Organization
Organization Name:GLYNDA R. MCCONVILLE, DDS, PA
Other - Org Name:SANDHILLS ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-718-9188
Mailing Address - Street 1:1129 CARTHAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4162
Mailing Address - Country:US
Mailing Address - Phone:919-718-9188
Mailing Address - Fax:919-718-0900
Practice Address - Street 1:1129 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4162
Practice Address - Country:US
Practice Address - Phone:919-718-9188
Practice Address - Fax:919-718-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7021261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083707475OtherINDIVIDUAL NPI NUMBER
NC5901535Medicaid