=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316612054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLY VAIL COTTEN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2021
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7701 TRENHOLM ROAD EXT
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-736-6000
-----------------------------------------------------
Fax | 803-736-6084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 GERVAIS ST APT 201
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-3097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-550-7060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DRP2369
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 10649PD
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 10474
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------