=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407847213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPSONVILLE DENTAL ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 W GEORGIA RD
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-963-3601
-----------------------------------------------------
Fax | 864-963-2598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 799
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-0799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-963-3601
-----------------------------------------------------
Fax | 864-963-2598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR PARTNER
-----------------------------------------------------
Name | DR. BROOKS A GODWIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 864-963-3601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------