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General NPI Number Information
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NPI Number | 1588407340
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Entity Type | Organization
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Legal Business Name | DENTRUST DENTAL SOUTH CAROLINA PC
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Dates
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Enumeration Date | 06/18/2024
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Last Update Date | 06/18/2024
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Provider Practice Location Address
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Address Line | 4712 LIBERTY DIVISION AVE
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City | COLUMBIA
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State | SC
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Zip | 29207-5405
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Country | US
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Telephone | 803-334-0530
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Fax |
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Provider Business Mailing Address
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Address Line | 1221 VINEWOOD DR
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City | SEFFNER
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State | FL
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Zip | 33584-4829
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Country | US
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Telephone | 813-451-4503
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CREDENTIALING
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Name | AMANDA CLARK
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Credential |
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Telephone | 267-927-5000
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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 |
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License Number State |
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