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General NPI Number Information
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NPI Number | 1386030351
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Entity Type | Organization
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Legal Business Name | VICTORY DENTISTRY FOR KIDS
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 04/07/2015
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Provider Practice Location Address
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Address Line | 9787 CHARLOTTE HWY STE 203
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City | INDIAN LAND
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State | SC
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Zip | 29707-5511
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Country | US
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Telephone | 803-547-2280
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Fax |
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Provider Business Mailing Address
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Address Line | 9787 CHARLOTTE HWY STE 203
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City | INDIAN LAND
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State | SC
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Zip | 29707-5511
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Country | US
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Telephone | 803-547-2280
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TASHIA MCDONALD
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Credential |
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Telephone | 803-228-0525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 4382
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License Number State | SC
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