1043256985 NPI number — DR. MARK WINSLOW ICARD D.D.S.

Table of content: DR. MARK WINSLOW ICARD D.D.S. (NPI 1043256985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043256985 NPI number — DR. MARK WINSLOW ICARD D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ICARD
Provider First Name:
MARK
Provider Middle Name:
WINSLOW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043256985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5500 HIGHWAY 49 S
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28075-8414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-455-5003
Provider Business Mailing Address Fax Number:
704-455-3587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5500 HIGHWAY 49 S
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28075-8414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-455-5003
Provider Business Practice Location Address Fax Number:
704-455-3587
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5668 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 94419 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8994419 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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