Provider Demographics
NPI:1356688857
Name:KERVIN MACK DMD MS PLLC
Entity type:Organization
Organization Name:KERVIN MACK DMD MS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:336-227-5594
Mailing Address - Street 1:1628 MEMORIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-3596
Mailing Address - Country:US
Mailing Address - Phone:336-227-5594
Mailing Address - Fax:
Practice Address - Street 1:1628 MEMORIAL DR STE C
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-3596
Practice Address - Country:US
Practice Address - Phone:336-227-5594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC88241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty