=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568673069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY DENTAL PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2329 DEVINE STREET
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-252-8101
-----------------------------------------------------
Fax | 803-779-7721
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 50664 2329 DEVINE STREET
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-252-8101
-----------------------------------------------------
Fax | 803-779-7721
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT CEO
-----------------------------------------------------
Name | DR. LORETTA KAY FELDER MCKELVEY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 803-252-8101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN013211
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401411265
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | SC2642
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------