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General NPI Number Information
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NPI Number | 1457898132
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Entity Type | Organization
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Legal Business Name | NEWBERRY DENTAL, PC
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Dates
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Enumeration Date | 01/19/2017
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Last Update Date | 01/19/2017
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Provider Practice Location Address
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Address Line | 2706 MAIN ST
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City | NEWBERRY
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State | SC
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Zip | 29108-4004
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Country | US
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Telephone | 803-276-2090
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Fax |
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Provider Business Mailing Address
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Address Line | 2706 MAIN ST
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City | NEWBERRY
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State | SC
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Zip | 29108-4004
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Country | US
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Telephone | 803-276-2090
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | JOHN CAMPBELL LAKE JR.
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Credential | DMD
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Telephone | 864-993-9061
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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 | 4593
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License Number State | SC
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