MEDICARE: DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.

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	:	1154265080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.

Provider Business Mailing Address
First Line	:	2641 BEAVER RUN BLVD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-5387
Country	:	US
Telephone Number	:	843-649-0000
Fax Number	:	843-649-0001

Provider Business Practice Location Address
First Line	:	2641 BEAVER RUN BLVD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-5387
Country	:	US
Telephone Number	:	843-649-0000
Fax Number	:	843-649-0001

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	CEMYIRA MCDOUGAL
Credential	:
Telephone Number	:	217-764-8609

Provider Enumeration Date	:	04/20/2026
Last Update Date	:	04/20/2026

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