MEDICARE: UPCOUNTRY DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1093522005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPCOUNTRY DENTAL, LLC

Provider Business Mailing Address
First Line	:	11 PROFESSIONALS CIR
Second Line	:
City	:	SENECA
State	:	SC
Zip	:	29678-2669
Country	:	US
Telephone Number	:	864-776-0123
Fax Number	:	864-776-0025

Provider Business Practice Location Address
First Line	:	11 PROFESSIONALS CIR
Second Line	:
City	:	SENECA
State	:	SC
Zip	:	29678-2669
Country	:	US
Telephone Number	:	864-776-0123
Fax Number	:	864-776-0025

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. ADRIENNE N WIMBROW
Credential	:	DMD
Telephone Number	:	864-776-0123

Provider Enumeration Date	:	12/12/2024
Last Update Date	:	12/12/2024

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Directions to “UPCOUNTRY DENTAL, LLC ” Practice Location

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