Healthcare Provider Details

I. General information

NPI: 1730740887
Provider Name (Legal Business Name): LOTUS DENTAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 BROADCLOTH ST STE 204
FORT MILL SC
29715-4507
US

IV. Provider business mailing address

1365 BROADCLOTH ST STE 204
FORT MILL SC
29715-4507
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-8858
  • Fax: 803-548-8860
Mailing address:
  • Phone: 803-548-8858
  • Fax: 803-548-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NHUNG PHAN
Title or Position: OWNER
Credential: DMD
Phone: 803-548-8858