MEDICARE: SOUTH LAKE FAMILY 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	:	1255691796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LAKE FAMILY DENTAL, LLC

Provider Business Mailing Address
First Line	:	1223 S LAKE DR
Second Line	:	SUITE A
City	:	LEXINGTON
State	:	SC
Zip	:	29073-6889
Country	:	US
Telephone Number	:	803-520-5580
Fax Number	:	803-520-5586

Provider Business Practice Location Address
First Line	:	1223 S LAKE DR
Second Line	:	SUITE A
City	:	LEXINGTON
State	:	SC
Zip	:	29073-6889
Country	:	US
Telephone Number	:	803-520-5580
Fax Number	:	803-520-5586

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANGELA SCHWEIGER
Credential	:	DMD
Telephone Number	:	803-520-5580

Provider Enumeration Date	:	05/17/2012
Last Update Date	:	05/17/2012

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