Provider Demographics
NPI:1245452333
Name:JAY J. COYLE DDS & ASSOCIATES PA
Entity type:Organization
Organization Name:JAY J. COYLE DDS & ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-540-5400
Mailing Address - Street 1:6923 SHANNON WILLOW RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1331
Mailing Address - Country:US
Mailing Address - Phone:704-540-5400
Mailing Address - Fax:704-540-6326
Practice Address - Street 1:491 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-540-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901933Medicaid