Healthcare Provider Details

I. General information

NPI: 1568114528
Provider Name (Legal Business Name): VAC ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 MERCANTILE PL STE 104
FORT MILL SC
29715-2102
US

IV. Provider business mailing address

482 MERCANTILE PL STE 104
FORT MILL SC
29715-2102
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-4255
  • Fax:
Mailing address:
  • Phone: 803-548-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURA HANSON VACCARIELLO
Title or Position: ORTHODONTIST
Credential: DMD
Phone: 803-548-4255