=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316543242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGEN CAMBRIDGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2020
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 SC HWY 72 BUSINESS
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-229-5885
-----------------------------------------------------
Fax | 864-229-1002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1302 SC HWY 72 BUSINESS
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-229-5885
-----------------------------------------------------
Fax | 864-229-1002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS
-----------------------------------------------------
Name | TIMOTHY MICHAEL SNIDER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 864-934-7131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------