=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124363858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPASS DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2012
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 WADE HAMPTON BLVD SUITE 118
-----------------------------------------------------
City | TAYLORS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29687-2781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-292-6050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 WADE HAMPTON BLVD SUITE 118
-----------------------------------------------------
City | TAYLORS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29687-2781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-292-6050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. SCOTT TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-561-7082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------