MEDICARE: FLAT ROCK FAMILY DENTISTRY

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	:	1891372710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLAT ROCK FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	520 S ALLEN RD STE 4
Second Line	:
City	:	FLAT ROCK
State	:	NC
Zip	:	28731-9451
Country	:	US
Telephone Number	:	828-693-0911
Fax Number	:	828-693-9529

Provider Business Practice Location Address
First Line	:	520 S ALLEN RD STE 4
Second Line	:
City	:	FLAT ROCK
State	:	NC
Zip	:	28731-9451
Country	:	US
Telephone Number	:	828-693-0911
Fax Number	:	828-693-9529

Authorized Official
Title or Position	:	DENTIST/PRESIDENT
Name	:	DR. SUSAN LOUISE OLCOTT
Credential	:	DMD, PA
Telephone Number	:	828-693-0911

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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