Healthcare Provider Details

I. General information

NPI: 1871570804
Provider Name (Legal Business Name): DAVID BRIAN TEVEPAUGH D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 SAINT JULIAN PL
COLUMBIA SC
29204-2409
US

IV. Provider business mailing address

1755 SAINT JULIAN PL
COLUMBIA SC
29204-2409
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-2972
  • Fax: 803-799-2151
Mailing address:
  • Phone: 803-254-2972
  • Fax: 803-799-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3085
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: