1154695112 NPI number — PHILIP BALD WATERFORD PLLC

Table of content: (NPI 1154695112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154695112 NPI number — PHILIP BALD WATERFORD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP BALD WATERFORD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL CENTER AT WATERFORD
Provider Other Organization Name Type Code:
3
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:
1154695112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 OLDE WATERFORD WAY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-383-0100
Provider Business Mailing Address Fax Number:
910-383-0121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 OLDE WATERFORD WAY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LELAND
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
28451-4171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-383-0100
Provider Business Practice Location Address Fax Number:
910-383-0121
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BALD
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
DENTIST-MEMBER MANAGER
Authorized Official Telephone Number:
910-202-4909

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  8308 , 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)





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