=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053887653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN AND ADULT DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2018
-----------------------------------------------------
Last Update Date | 10/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7210K BROAD RIVER RD
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-7973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-407-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7210K BROAD RIVER RD
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-7973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | TONIA PATTERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-600-7211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------