MEDICARE: OMNI DENTAL OF SUMTER 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	:	1275356289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI DENTAL OF SUMTER LLC

Provider Business Mailing Address
First Line	:	212 OUTLET POINTE BLVD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-5667
Country	:	US
Telephone Number	:	803-830-3008
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 CONSTITUTION DR
Second Line	:
City	:	SUMTER
State	:	SC
Zip	:	29154-8190
Country	:	US
Telephone Number	:	803-773-5413
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT ELLIS
Credential	:	DMD
Telephone Number	:	803-413-5100

Provider Enumeration Date	:	11/07/2024
Last Update Date	:	11/07/2024

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Directions to “OMNI DENTAL OF SUMTER LLC ” Practice Location

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