=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629025564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S C TOLBERT DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 05/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3419 C MELROSE RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-6116
-----------------------------------------------------
Fax | 910-484-5950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3419 C MELROSE RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-6116
-----------------------------------------------------
Fax | 910-484-5950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | S C TOLBERT
-----------------------------------------------------
Credential | D D S P A
-----------------------------------------------------
Telephone | 910-484-6116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 3726
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------