=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851945497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. KACY WONDER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2019
-----------------------------------------------------
Last Update Date | 08/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 173 ASHLEY AVENUE ROOM 453 MSC 507
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-729-0791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 WESTEDGE STREET UNIT 302
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-468-5862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 9435
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------