Provider Demographics
NPI:1548953870
Name:STORY, AVANA L (DMD)
Entity type:Individual
Prefix:
First Name:AVANA
Middle Name:L
Last Name:STORY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E BROOKLYN VILLAGE AVE UNIT 1506
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3632
Mailing Address - Country:US
Mailing Address - Phone:404-558-9191
Mailing Address - Fax:
Practice Address - Street 1:1108 E DIXON BLVD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-6840
Practice Address - Country:US
Practice Address - Phone:704-284-5174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC139541223G0001X
AL1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool