Healthcare Provider Details

I. General information

NPI: 1124635495
Provider Name (Legal Business Name): DESTINATION DENTAL OF DUNCAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 DEACON TILLER CT
DUNCAN SC
29334-8880
US

IV. Provider business mailing address

401 COMMERCE DR STE 108
FORT WASHINGTON PA
19034-2724
US

V. Phone/Fax

Practice location:
  • Phone: 864-485-2214
  • Fax: 864-485-2215
Mailing address:
  • Phone: 215-550-4590
  • Fax: 215-646-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. NIRANJAN SAVANI
Title or Position: OWNER
Credential: DMD
Phone: 215-550-4590