Individual
LEI SHI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
8511 CANTILEVER WAY STE 101, RALEIGH, NC 27613-6996
(919) 278-7576
Mailing address
8511 CANTILEVER WAY STE 101, RALEIGH, NC 27613-6996
(919) 278-7576
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
11011
NC
Other
Enumeration date
05/25/2018
Last updated
04/26/2025
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