Healthcare Provider Details

I. General information

NPI: 1770799868
Provider Name (Legal Business Name): KIMBERLY BODIFORD MOSES RDH, BHS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OLD CHEROKEE RD SUITE F PMB 14
LEXINGTON SC
29072-9316
US

IV. Provider business mailing address

432 DELMONT DR
GOOSE CREEK SC
29445-3609
US

V. Phone/Fax

Practice location:
  • Phone: 803-808-2950
  • Fax: 803-808-5642
Mailing address:
  • Phone: 843-830-2479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3346
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: