Healthcare Provider Details

I. General information

NPI: 1093718009
Provider Name (Legal Business Name): CHARLES S. BEBKO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W O EZELL BLVD STE. B
SPARTANBURG SC
29301-1655
US

IV. Provider business mailing address

1111 W O EZELL BLVD STE. B
SPARTANBURG SC
29301-1655
US

V. Phone/Fax

Practice location:
  • Phone: 864-576-0947
  • Fax: 864-576-7989
Mailing address:
  • Phone: 864-576-0947
  • Fax: 864-576-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2390
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: