=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275764672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMERVILLE PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2009
-----------------------------------------------------
Last Update Date | 08/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 W 5TH NORTH ST STE A
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29483-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-871-6433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 W 5TH NORTH ST STE A
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29483-6515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-871-6433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOROTHY M BAKER
-----------------------------------------------------
Credential | DMD PC
-----------------------------------------------------
Telephone | 873-871-6433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 3903
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------