MEDICARE: ERIN PRUITT, DMD, PA

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	4460	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154722163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERIN PRUITT, DMD, PA

Provider Business Mailing Address
First Line	:	870 CLEVELAND ST STE 2C
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-4428
Country	:	US
Telephone Number	:	864-282-8555
Fax Number	:

Provider Business Practice Location Address
First Line	:	870 CLEVELAND ST STE 2C
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-4428
Country	:	US
Telephone Number	:	864-282-8555
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	ERIN PRUITT
Credential	:	D.M.D.
Telephone Number	:	864-282-8555

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	09/09/2014

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