Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 3233 | NC |
NPI | 1093777120 |
---|---|
Provider Name | Dr. Pendleton Glass Waldron |
First Address | Newton, NC 28658 |
Second Address | Newton, NC 28658 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8998815 | (05) | NC |
98815 | BCBS (01) | NC |
U35469 | (02) |