Provider Demographics
NPI:1669240586
Name:CAROLINA PEDIATRIC DENTAL MANAGEMENT, LLC
Entity type:Organization
Organization Name:CAROLINA PEDIATRIC DENTAL MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-550-5440
Mailing Address - Street 1:13580 GROUPE DR STE 305
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-570-0180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty