Provider Demographics
NPI:1588756803
Name:DR. JON C. PACKMAN PLLC
Entity type:Organization
Organization Name:DR. JON C. PACKMAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:PACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-873-2211
Mailing Address - Street 1:104 BILLINSGATE CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6702
Mailing Address - Country:US
Mailing Address - Phone:704-799-7552
Mailing Address - Fax:
Practice Address - Street 1:1316 DAVIE AVE STE A
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3561
Practice Address - Country:US
Practice Address - Phone:704-873-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899015PMedicaid