Healthcare Provider Details

I. General information

NPI: 1346658762
Provider Name (Legal Business Name): SHOBHA DENTAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6260 HIGHWAY 76
PENDLETON SC
29670-9148
US

IV. Provider business mailing address

6260 HIGHWAY 76
PENDLETON SC
29670-9148
US

V. Phone/Fax

Practice location:
  • Phone: 864-332-0530
  • Fax:
Mailing address:
  • Phone: 864-332-0530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3738
License Number StateSC

VIII. Authorized Official

Name: DR. VASANTHA RAO
Title or Position: OWNER
Credential: DMD
Phone: 864-332-0530