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General NPI Number Information
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NPI Number | 1740646769
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Entity Type | Organization
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Legal Business Name | TRIDENT DENTAL SPECIALTY PARTNERS
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Dates
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Enumeration Date | 01/06/2016
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Last Update Date | 01/06/2016
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Provider Practice Location Address
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Address Line | 6335 DORCHESTER RD
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City | CHARLESTON
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State | SC
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Zip | 29418-5103
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Country | US
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Telephone | 843-552-2580
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Fax |
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Provider Business Mailing Address
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Address Line | 6335 DORCHESTER RD
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City | CHARLESTON
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State | SC
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Zip | 29418-5103
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Country | US
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Telephone | 843-552-2580
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DR. MARK YAMPOLSKY
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Credential | DDS
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Telephone | 843-552-2580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2962
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License Number State | SC
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