=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710365366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE DENTAL SPA AND SALON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2015
-----------------------------------------------------
Last Update Date | 05/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 MALPHRUS RD STE 115
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-837-4444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 MALPHRUS RD STE 115
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-837-4444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GEORGE K CAMP
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 843-837-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3654
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------