Provider Demographics
NPI:1063700334
Name:WAKE CROSS ROADS DENTISTRY
Entity type:Organization
Organization Name:WAKE CROSS ROADS DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-802-8508
Mailing Address - Street 1:2303 W MOREHEAD ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5186
Mailing Address - Country:US
Mailing Address - Phone:704-304-5513
Mailing Address - Fax:
Practice Address - Street 1:2303 W MOREHEAD ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5186
Practice Address - Country:US
Practice Address - Phone:704-304-5513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40101223G0001X
NC79701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty