Healthcare Provider Details

I. General information

NPI: 1437607413
Provider Name (Legal Business Name): KENT TANNER WASHINGTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 CONSTITUTION DR
SUMTER SC
29154-8190
US

IV. Provider business mailing address

400 MALLET HILL RD APT D1
COLUMBIA SC
29223-5726
US

V. Phone/Fax

Practice location:
  • Phone: 803-699-9989
  • Fax: 803-699-8035
Mailing address:
  • Phone: 803-699-9989
  • Fax: 803-699-8035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8136
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: