Provider Demographics
NPI:1821555020
Name:SURGICAL CENTER FOR DENTAL PROFESSIONALS OF NC LLC
Entity type:Organization
Organization Name:SURGICAL CENTER FOR DENTAL PROFESSIONALS OF NC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-340-1840
Mailing Address - Street 1:2620 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1821
Mailing Address - Country:US
Mailing Address - Phone:919-526-1000
Mailing Address - Fax:
Practice Address - Street 1:2620 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1821
Practice Address - Country:US
Practice Address - Phone:919-526-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURGICAL CENTER FOR DENTAL PROFESSIONALS OF NC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-23
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty