=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487436267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIA PORACH DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2023
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1585 SKYLYN DR
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29307-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-385-2119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 479 FOX RUN TRL
-----------------------------------------------------
City | WOODRUFF
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29388-9812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-273-1658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10458
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------