=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811361579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE KNOLL COMPREHENSIVE DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2015
-----------------------------------------------------
Last Update Date | 11/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1825 S LAKE DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-785-9991
-----------------------------------------------------
Fax | 803-785-6921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1825 S LAKE DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-785-9991
-----------------------------------------------------
Fax | 803-785-6921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE COORDINATOR
-----------------------------------------------------
Name | MRS. PAMELA SUZANNE COCKRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-785-9991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2790
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------