=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598973430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAYCE FAMILY DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 08/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1313 STATE ST
-----------------------------------------------------
City | CAYCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29033-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-796-1734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1313 STATE ST
-----------------------------------------------------
City | CAYCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29033-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. GREGORY A. MILLWOOD
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 803-796-1734
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3904
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------