=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164553178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL ASSOCIATES OF HOLLY HILL PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 HOLLY STREET
-----------------------------------------------------
City | HOLLY HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29059-0606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-496-5093
-----------------------------------------------------
Fax | 803-496-5093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 606
-----------------------------------------------------
City | HOLLY HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29059-0606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-496-5093
-----------------------------------------------------
Fax | 803-496-5093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESTIDENT
-----------------------------------------------------
Name | IVAN ANDERSON BISHOP JR.
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 803-496-5093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DC41076-1
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------