Provider Demographics
NPI:1255627915
Name:ANTONIO S. BRAITHWAITE DDS MPH PA
Entity type:Organization
Organization Name:ANTONIO S. BRAITHWAITE DDS MPH PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:BRAITHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:919-260-1154
Mailing Address - Street 1:136 CARBONTON RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4000
Mailing Address - Country:US
Mailing Address - Phone:919-718-5561
Mailing Address - Fax:919-718-5562
Practice Address - Street 1:136 CARBONTON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4000
Practice Address - Country:US
Practice Address - Phone:919-718-5561
Practice Address - Fax:919-718-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty