Provider Demographics
NPI:1720521982
Name:TIMOTHY O IMAFIDON JR DDS PA
Entity Type:Organization
Organization Name:TIMOTHY O IMAFIDON JR DDS PA
Other - Org Name:GOLDSBORO PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:O
Authorized Official - Last Name:IMAFIDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-274-7304
Mailing Address - Street 1:300 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-4807
Mailing Address - Country:US
Mailing Address - Phone:919-947-0800
Mailing Address - Fax:
Practice Address - Street 1:300 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-4807
Practice Address - Country:US
Practice Address - Phone:919-947-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10244261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental