Provider Demographics
NPI:1336366541
Name:COYLE, JAY J
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:J
Last Name:COYLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6923 SHANNON WILLOW RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1331
Mailing Address - Country:US
Mailing Address - Phone:704-540-5400
Mailing Address - Fax:704-540-6326
Practice Address - Street 1:491 N. WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-540-5400
Practice Address - Fax:704-540-5400
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991824Medicaid