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General NPI Number Information
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NPI Number | 1417908328
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Entity Type | Individual
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Provider Name | MARK ANTHONY CHISHOM DMD
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Gender | Male
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 04/02/2015
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Provider Practice Location Address
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Address Line | 102 BUCKTHORN CIR
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City | ELGIN
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State | SC
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Zip | 29045-8695
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Country | US
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Telephone | 803-477-4909
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Fax |
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Provider Business Mailing Address
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Address Line | 102 BUCKTHORN CIR
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City | ELGIN
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State | SC
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Zip | 29045-8695
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Country | US
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Telephone | 803-477-4909
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 3253
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN014013
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License Number State | GA
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