MEDICARE: SPARKLE DENTAL CENTER INC.

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1104243740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKLE DENTAL CENTER INC.

Provider Business Mailing Address
First Line	:	PO BOX 1861
Second Line	:
City	:	GEORGETOWN
State	:	SC
Zip	:	29442-1861
Country	:	US
Telephone Number	:	843-833-3555
Fax Number	:

Provider Business Practice Location Address
First Line	:	8848 HIGHWAY 17 BYP S
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7739
Country	:	US
Telephone Number	:	843-650-6700
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CAMERON JULIUS BANKS
Credential	:	PSY.D
Telephone Number	:	843-833-3555

Provider Enumeration Date	:	03/20/2014
Last Update Date	:	03/20/2014

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