MEDICARE: DRS J LOVELAND AND R WALKER IV, 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

General Provider Information

NPI Number	:	1538865183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRS J LOVELAND AND R WALKER IV, LLC

Provider Business Mailing Address
First Line	:	19315 W CATAWBA AVE STE 104
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-8651
Country	:	US
Telephone Number	:	704-960-2492
Fax Number	:

Provider Business Practice Location Address
First Line	:	749 STOCKBRIDGE DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7200
Country	:	US
Telephone Number	:	704-960-2492
Fax Number	:

Authorized Official
Title or Position	:	DENTIST, OWNER
Name	:	JENNIFER ANN LOVELAND
Credential	:	DMD
Telephone Number	:	704-960-2492

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	02/06/2023

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