Provider Demographics
NPI:1700996816
Name:PEEDIN, CLYDE DOUGLAS JR (DDS)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:DOUGLAS
Last Name:PEEDIN
Suffix:JR
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 1:110 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27820
Mailing Address - Country:US
Mailing Address - Phone:252-537-0438
Mailing Address - Fax:252-537-0430
Practice Address - Street 1:110 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27820
Practice Address - Country:US
Practice Address - Phone:252-537-0438
Practice Address - Fax:252-537-0430
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996771Medicaid