Provider Demographics
NPI:1134184096
Name:CIVILS, JOHN DAVID JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:CIVILS
Suffix:JR
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 13646
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415
Mailing Address - Country:US
Mailing Address - Phone:336-272-4177
Mailing Address - Fax:336-272-6313
Practice Address - Street 1:1114 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401
Practice Address - Country:US
Practice Address - Phone:336-272-4177
Practice Address - Fax:336-272-6313
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7218122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902V5Medicaid
NC902V5OtherBCBS