=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972073831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2018
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 WOODRUFF RD
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-540-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 WOODRUFF RD
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-963-7000
-----------------------------------------------------
Fax | 864-263-7488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | JESSICA BRITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------