Healthcare Provider Details

I. General information

NPI: 1104629534
Provider Name (Legal Business Name): COLE DATTEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

2526 ANNIE BAXTER AVE
JOPLIN MO
64804-0333
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-7111
  • Fax:
Mailing address:
  • Phone: 913-948-0595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number97317
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number97317
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: