Healthcare Provider Details

I. General information

NPI: 1528068236
Provider Name (Legal Business Name): TERRY LYNN KUNKLE SR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 LIBRARY ST
MONCKS CORNER SC
29461-3751
US

IV. Provider business mailing address

119 LIBRARY ST
MONCKS CORNER SC
29461-3751
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-8065
  • Fax: 843-761-5085
Mailing address:
  • Phone: 843-761-8065
  • Fax: 843-761-5085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberSC 1641
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: