Provider Demographics
NPI:1285771675
Name:IRVING, JOHANNA SERLETIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:SERLETIS
Last Name:IRVING
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 SUNNYBROOK RD
Practice Address - Street 2:CLINIC D, 2ND FLOOR
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1808
Practice Address - Country:US
Practice Address - Phone:919-250-4616
Practice Address - Fax:919-212-9684
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice