Provider Demographics
NPI:1447364674
Name:SUMMERVILLE, WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SUMMERVILLE
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 1:475 N WENDOVER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1064
Mailing Address - Country:US
Mailing Address - Phone:704-540-5400
Mailing Address - Fax:704-364-5293
Practice Address - Street 1:475 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:704-364-5293
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900137Medicaid
NC9027KOtherBCBS PROVIDER NUMBER