Provider Demographics
NPI: | 1952347437 |
---|---|
Name: | CLEMENT B WOODARD DDS PA |
Entity Type: | Organization |
Organization Name: | CLEMENT B WOODARD DDS PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | CLEMENT |
Authorized Official - Middle Name: | BENSON |
Authorized Official - Last Name: | WOODARD |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 252-291-7510 |
Mailing Address - Street 1: | 2401 WOOTEN BLVD SW |
Mailing Address - Street 2: | SUITE A |
Mailing Address - City: | WILSON |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27893-4464 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 252-291-7510 |
Mailing Address - Fax: | 252-291-7531 |
Practice Address - Street 1: | 2401 WOOTEN BLVD SW |
Practice Address - Street 2: | SUITE A |
Practice Address - City: | WILSON |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27893-4464 |
Practice Address - Country: | US |
Practice Address - Phone: | 252-291-7510 |
Practice Address - Fax: | 252-291-7531 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-06-21 |
Last Update Date: | 2007-11-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 3744 | 261QD0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |