Healthcare Provider Details

I. General information

NPI: 1154265080
Provider Name (Legal Business Name): DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 BEAVER RUN BLVD
SURFSIDE BEACH SC
29575-5387
US

IV. Provider business mailing address

2641 BEAVER RUN BLVD
SURFSIDE BEACH SC
29575-5387
US

V. Phone/Fax

Practice location:
  • Phone: 843-649-0000
  • Fax: 843-649-0001
Mailing address:
  • Phone: 843-649-0000
  • Fax: 843-649-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CEMYIRA MCDOUGAL
Title or Position: CREDENTIALING
Credential:
Phone: 217-764-8609