Provider Demographics
NPI:1396084216
Name:BIRKDALE FAMILY AND COSMETIC DENTISTRY
Entity type:Organization
Organization Name:BIRKDALE FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-896-5225
Mailing Address - Street 1:8712 LINDHOLM DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8712 LINDHOLM DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-1870
Practice Address - Country:US
Practice Address - Phone:704-896-5225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918849Medicaid