Provider Demographics
NPI:1184613531
Name:CONGLETON, JIM (DDS)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:
Last Name:CONGLETON
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 1:2811 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:TRENT WOODS
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7351
Mailing Address - Country:US
Mailing Address - Phone:252-633-0424
Mailing Address - Fax:252-638-6662
Practice Address - Street 1:2811 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:TRENT WOODS
Practice Address - State:NC
Practice Address - Zip Code:28562-7351
Practice Address - Country:US
Practice Address - Phone:252-633-0424
Practice Address - Fax:252-638-6662
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU35859Medicare UPIN
NC8991755Medicare ID - Type Unspecified