Healthcare Provider Details

I. General information

NPI: 1073967303
Provider Name (Legal Business Name): SUMMERHILL FAMILY & COSMETIC DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 04/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 SUMMERHILL RD
NORTH AUGUSTA SC
29841-3067
US

IV. Provider business mailing address

1604 SUMMERHILL RD
NORTH AUGUSTA SC
29841-3067
US

V. Phone/Fax

Practice location:
  • Phone: 803-279-6743
  • Fax:
Mailing address:
  • Phone: 803-279-6743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDGD.8561 GD
License Number StateSC

VIII. Authorized Official

Name: DR. HIEU NGOC PHAN
Title or Position: DENTIST
Credential: DMD
Phone: 803-397-9115