MEDICARE: NASH ORTHODONTICS PRACTICE 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	261QD0000X	Dental Clinic/Center	4149	SC

General Provider Information

NPI Number	:	1326206129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NASH ORTHODONTICS PRACTICE LLC

Provider Business Mailing Address
First Line	:	1127 QUEENSBOROUGH BLVD
Second Line	:	SUITE 107
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-5431
Country	:	US
Telephone Number	:	843-884-6336
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 QUEENSBOROUGH BLVD
Second Line	:	SUITE 107
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-5431
Country	:	US
Telephone Number	:	843-884-6336
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. TRAVIS D NASH
Credential	:	DDS
Telephone Number	:	843-884-6336

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	05/28/2008

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