Healthcare Provider Details

I. General information

NPI: 1295669927
Provider Name (Legal Business Name): COLE PROSSER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1652 CHURCH ST
CONWAY SC
29526-2962
US

IV. Provider business mailing address

552 WILDFLOWER TRL
MYRTLE BEACH SC
29579-7220
US

V. Phone/Fax

Practice location:
  • Phone: 843-733-3387
  • Fax:
Mailing address:
  • Phone: 843-655-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11422
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: