Healthcare Provider Details

I. General information

NPI: 1184682585
Provider Name (Legal Business Name): MARK LANGLEY MCINNIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 FRONTAGE RD STE 1
CLEMSON SC
29631
US

IV. Provider business mailing address

201 FRONTAGE RD STE 1
CLEMSON SC
29631
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-7534
  • Fax: 864-654-4830
Mailing address:
  • Phone: 864-654-7534
  • Fax: 864-654-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3514 SPEC 0504
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0504
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3514
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: