=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932376035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY DENTAL CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2008
-----------------------------------------------------
Last Update Date | 05/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 W FRONT ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29657-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-843-3742
-----------------------------------------------------
Fax | 864-843-3744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 W FRONT ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29657-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-843-3742
-----------------------------------------------------
Fax | 864-843-3744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. JAMES L WILSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 864-843-3742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3144
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------