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General NPI Number Information
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NPI Number | 1821485640
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Entity Type | Organization
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Legal Business Name | THE DENTAL RETREAT AT MOUNTAIN PARK
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Dates
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Enumeration Date | 04/20/2015
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Last Update Date | 04/20/2015
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Provider Practice Location Address
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Address Line | 125 BOTANICAL CIR
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City | TRAVELERS REST
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State | SC
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Zip | 29690-7112
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Country | US
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Telephone | 864-836-3611
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Fax | 888-778-6022
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Provider Business Mailing Address
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Address Line | 125 BOTANICAL CIR
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City | TRAVELERS REST
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State | SC
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Zip | 29690-7112
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Country | US
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Telephone | 864-836-3611
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Fax | 888-778-6022
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Authorized Official
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Title or Position | OWNER
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Name | DR. JON MICHEAL JULIAN
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Credential | DDS
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Telephone | 864-836-3611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 6984
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License Number State | SC
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