Provider Demographics
NPI:1962558692
Name:RENFRO, JOHN FARRELL (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:FARRELL
Last Name:RENFRO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 SPICEWOOD RD
Mailing Address - Street 2:P.O. BOX 398
Mailing Address - City:BURNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28714-6058
Mailing Address - Country:US
Mailing Address - Phone:828-682-2313
Mailing Address - Fax:
Practice Address - Street 1:584 SPICEWOOD RD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-6058
Practice Address - Country:US
Practice Address - Phone:828-682-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997337Medicaid
NC8997337Medicaid