MEDICARE: DR. RICHARD FRED AMENDOLA DDS

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	3856	SC

General Provider Information

NPI Number	:	1790866606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD FRED AMENDOLA DDS

Provider Business Mailing Address
First Line	:	1197 N LAKE DR
Second Line	:	B
City	:	LEXINGTON
State	:	SC
Zip	:	29072-7645
Country	:	US
Telephone Number	:	803-359-6130
Fax Number	:	803-359-4218

Provider Business Practice Location Address
First Line	:	1197 N LAKE DR
Second Line	:	B
City	:	LEXINGTON
State	:	SC
Zip	:	29072-7645
Country	:	US
Telephone Number	:	803-359-6130
Fax Number	:	803-359-4218

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	07/08/2007

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