Provider Demographics
NPI:1134154651
Name:CT MAXILLOFACIAL IMAGING, LLC
Entity type:Organization
Organization Name:CT MAXILLOFACIAL IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-484-3000
Mailing Address - Street 1:3415A MELROSE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1608
Mailing Address - Country:US
Mailing Address - Phone:910-484-3000
Mailing Address - Fax:
Practice Address - Street 1:3415A MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1608
Practice Address - Country:US
Practice Address - Phone:910-484-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Single Specialty