Provider Demographics
NPI:1295264372
Name:FAW, JEREMIAH JAMES (DDS)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JAMES
Last Name:FAW
Suffix:
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 1:1915 W PARK DR STE 104
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3777
Mailing Address - Country:US
Mailing Address - Phone:336-903-9399
Mailing Address - Fax:336-903-0464
Practice Address - Street 1:1915 W PARK DR STE 104
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3777
Practice Address - Country:US
Practice Address - Phone:336-903-9399
Practice Address - Fax:336-903-0464
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC107061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice