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General NPI Number Information
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NPI Number | 1417053406
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Entity Type | Organization
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Legal Business Name | LAKE BOWEN DENTAL
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8810 HWY 9
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City | INMAN
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State | SC
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Zip | 29349
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Country | US
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Telephone | 864-592-1647
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Fax | 864-592-0630
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Provider Business Mailing Address
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Address Line | PO BOX 38
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City | INMAN
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State | SC
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Zip | 29349
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Country | US
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Telephone | 864-592-1647
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Fax | 864-592-0630
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. ASA DUNCAN SHIRLEY III
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Credential | DMD
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Telephone | 864-592-1647
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | SC1228
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | SC3766
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | SC1863
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License Number State | SC
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