=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851858013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE TOT SPOT OF SOUTH CAROLINA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2019
-----------------------------------------------------
Last Update Date | 02/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1334 S. HWY 14
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-297-5585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1334 S. HWY 14
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-297-5585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANN BYNUM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 864-297-5585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------