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General NPI Number Information
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NPI Number | 1295961274
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Entity Type | Organization
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Legal Business Name | CAPITOL DENTAL GROUP, LLC
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Dates
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Enumeration Date | 06/04/2009
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Last Update Date | 06/04/2009
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Provider Practice Location Address
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Address Line | 1106 ANTHONY AVE
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City | COLUMBIA
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State | SC
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Zip | 29201-1730
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Country | US
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Telephone | 803-252-4500
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Fax | 803-252-0334
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Provider Business Mailing Address
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Address Line | 1106 ANTHONY AVE
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City | COLUMBIA
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State | SC
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Zip | 29201-1730
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Country | US
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Telephone | 803-252-4500
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Fax | 803-252-0334
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ROBET MICHAEL JOHNSON
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Credential | D.M.D.
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Telephone | 803-252-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | SC-4484
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | SC-2275
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License Number State | SC
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