=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144370339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILIP PRICKETT/ MT. PLEASANT ORAL FACIAL & IMPLANT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 06/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1311 CHUCK DAWLEY BLVD STE 101
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464-7303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-971-0041
-----------------------------------------------------
Fax | 843-971-0043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7465A NORTHSIDE DR
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29420-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-797-7600
-----------------------------------------------------
Fax | 843-797-7905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. PHILIP M PRICKETT
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 843-971-0041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 1481
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 3132
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------