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General NPI Number Information
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NPI Number | 1770918351
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Entity Type | Organization
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Legal Business Name | PEDO CAROLINA, INC.
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Dates
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Enumeration Date | 09/13/2013
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Last Update Date | 09/13/2013
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Provider Practice Location Address
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Address Line | 2460 INDIA HOOK RD STE 106
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City | ROCK HILL
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State | SC
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Zip | 29732-3530
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Country | US
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Telephone | 704-763-4931
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Fax |
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Provider Business Mailing Address
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Address Line | 2460 INDIA HOOK RD STE 106
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City | ROCK HILL
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State | SC
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Zip | 29732-3530
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Country | US
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Telephone | 704-763-4931
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | JONATHAN MARK MITCHELL
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Credential | DMD, PHD, MSD
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Telephone | 704-763-4931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 4509-798
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License Number State | SC
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