MEDICARE: DENTAL PROFESSIONALS 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	:	1265777353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.

Provider Business Mailing Address
First Line	:	131 HARBISON BLVD STE G
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2226
Country	:	US
Telephone Number	:	803-661-9529
Fax Number	:	803-661-9783

Provider Business Practice Location Address
First Line	:	131 HARBISON BLVD STE G
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2226
Country	:	US
Telephone Number	:	803-661-9529
Fax Number	:	803-661-9783

Authorized Official
Title or Position	:	INSURANCE/CREDENTIALING
Name	:	COURTNEY MINTON
Credential	:
Telephone Number	:	217-540-5699

Provider Enumeration Date	:	11/30/2012
Last Update Date	:	12/31/2012

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