Provider Demographics
NPI:1801973524
Name:BALD, PHILIP FRANCIS (DMD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:FRANCIS
Last Name:BALD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 ANTELOPE TRL
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3191
Mailing Address - Country:US
Mailing Address - Phone:252-489-9063
Mailing Address - Fax:
Practice Address - Street 1:609 W KITTY HAWK RD
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-4231
Practice Address - Country:US
Practice Address - Phone:252-261-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913394Medicaid