MEDICARE: ADVANCED DENTISTRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	8470	SC

General Provider Information

NPI Number	:	1053810788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	3708 MAIDSTONE DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7545
Country	:	US
Telephone Number	:	843-291-8999
Fax Number	:

Provider Business Practice Location Address
First Line	:	1149 OAKLAND MARKET RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-8220
Country	:	US
Telephone Number	:	843-291-8999
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CANDICE M VINSON
Credential	:	DMD
Telephone Number	:	843-291-8999

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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