=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861649386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE SMILES DENTAL, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2008
-----------------------------------------------------
Last Update Date | 02/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9020 FARROW RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-9773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-419-5002
-----------------------------------------------------
Fax | 803-419-9600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9020 FARROW RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203-9773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-419-5002
-----------------------------------------------------
Fax | 803-419-9600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | ANDREW G GAMBRELL
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 803-419-5002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | SC2116
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30-04295
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 03794
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2116
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3794
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------