=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063689503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMETTO DENTURE CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2008
-----------------------------------------------------
Last Update Date | 07/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 N CHURCH ST
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-582-4308
-----------------------------------------------------
Fax | 864-596-4492
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 975 N CHURCH ST
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29303-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-582-4308
-----------------------------------------------------
Fax | 864-596-4492
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MRS. CHRIS F JUST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-582-4308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------