Provider Demographics
NPI:1720121718
Name:KOONCE, SAMUEL G JR (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:KOONCE
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:PO BOX 965
Mailing Address - Street 2:900 SPIVEY RD
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0965
Mailing Address - Country:US
Mailing Address - Phone:910-642-4529
Mailing Address - Fax:910-642-4354
Practice Address - Street 1:900 SPIVEY RD
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472
Practice Address - Country:US
Practice Address - Phone:910-642-4529
Practice Address - Fax:910-642-4354
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC43651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995053Medicaid