MEDICARE: MEDICAID DENTAL PRACTICE OF EASLEY, SC, INC

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	3944	SC

General Provider Information

NPI Number	:	1932399862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAID DENTAL PRACTICE OF EASLEY, SC, INC

Provider Business Mailing Address
First Line	:	415 S PENDLETON ST
Second Line	:
City	:	EASLEY
State	:	SC
Zip	:	29640-3072
Country	:	US
Telephone Number	:	864-859-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 S PENDLETON ST
Second Line	:
City	:	EASLEY
State	:	SC
Zip	:	29640-3527
Country	:	US
Telephone Number	:	864-855-6530
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHAWN C EDWARDS
Credential	:	DDS
Telephone Number	:	864-859-0111

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	07/26/2007

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