MEDICARE: IGRIN CHILDRENS DENTISTRY 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1245603539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IGRIN CHILDRENS DENTISTRY LLC

Provider Business Mailing Address
First Line	:	1860 OLD FURNACE RD.
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316
Country	:	US
Telephone Number	:	864-592-1647
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 OLD FURNACE ROAD
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-6623
Country	:	US
Telephone Number	:	864-592-1647
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE COORDINATOR
Name	:	BRENT ALLEN AYERS
Credential	:
Telephone Number	:	864-561-7559

Provider Enumeration Date	:	11/09/2015
Last Update Date	:	11/09/2015

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