Provider Demographics
NPI:1730272402
Name:CHILDERS, DALE A (DDS)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:A
Last Name:CHILDERS
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 1:2409 ROBESON STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305
Mailing Address - Country:US
Mailing Address - Phone:910-483-9546
Mailing Address - Fax:910-483-8550
Practice Address - Street 1:2409 ROBESON STREET
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305
Practice Address - Country:US
Practice Address - Phone:910-483-9546
Practice Address - Fax:910-483-8550
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC49731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991553Medicaid
NC467383OtherINDIVIDUAL #-UNITED CONCO
NC955715OtherGROUP #-UNITED CONCORDIA
NC890138FMedicaid
NC467383OtherINDIVIDUAL #-UNITED CONCO
NCT63841Medicare UPIN
NC890138FMedicaid