=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902034903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID LATHAM DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 01/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 960 CIPRIANA DR UNIT B6
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29572-4627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-839-9552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2521 GREAT SCOTT DR
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58369
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7480754-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8462
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------