Healthcare Provider Details

I. General information

NPI: 1255384038
Provider Name (Legal Business Name): RONALD BRENT CALCUTT JR. D.M.D., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RON B CALCUTT JR. D.M.D.,P.A.

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N MAIN ST
FOUNTAIN INN SC
29644-1611
US

IV. Provider business mailing address

508 WALKINGSTICK WAY
SIMPSONVILLE SC
29680-7216
US

V. Phone/Fax

Practice location:
  • Phone: 864-862-2966
  • Fax: 864-862-2112
Mailing address:
  • Phone: 864-228-7297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3875
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: