Healthcare Provider Details

I. General information

NPI: 1730602202
Provider Name (Legal Business Name): AMELIA BAXLEY ABERCROMBIE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMELIA SIKES BAXLEY DMD

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 W MARK BLVD
SUMTER SC
29150-1900
US

IV. Provider business mailing address

752 MATTISON AVE
SUMTER SC
29150-3108
US

V. Phone/Fax

Practice location:
  • Phone: 803-905-3567
  • Fax:
Mailing address:
  • Phone: 803-528-9092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9847
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10788
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: