Healthcare Provider Details

I. General information

NPI: 1760392617
Provider Name (Legal Business Name): SWEET GRASS DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SAINT MARK RD
TAYLORS SC
29687-5233
US

IV. Provider business mailing address

50 SAINT MARK RD
TAYLORS SC
29687-5233
US

V. Phone/Fax

Practice location:
  • Phone: 215-313-4189
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JYOTHSNA MEDA
Title or Position: DR.
Credential: DMD
Phone: 215-313-4189