Provider Demographics
NPI:1912170499
Name:DAVID J MAYBERRY, DDS, PA
Entity Type:Organization
Organization Name:DAVID J MAYBERRY, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-637-1232
Mailing Address - Street 1:1539 E INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-6117
Mailing Address - Country:US
Mailing Address - Phone:704-637-1232
Mailing Address - Fax:704-637-0446
Practice Address - Street 1:1539 E INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-6117
Practice Address - Country:US
Practice Address - Phone:704-637-1232
Practice Address - Fax:704-637-0446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC47921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995584Medicaid