Provider Demographics
NPI:1740325232
Name:SERY, LAETITIA IFEYINWA (DDS)
Entity type:Individual
Prefix:DR
First Name:LAETITIA
Middle Name:IFEYINWA
Last Name:SERY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 E GARRISON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5144
Mailing Address - Country:US
Mailing Address - Phone:704-860-0945
Mailing Address - Fax:
Practice Address - Street 1:1367 E GARRISON BLVD STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5144
Practice Address - Country:US
Practice Address - Phone:704-860-0945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2014-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8474122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8474OtherNC STATE BOARD