MEDICARE: RIVERS AVENUE DENTAL HEALTH CENTER

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	2464	SC

General Provider Information

NPI Number	:	1295134419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERS AVENUE DENTAL HEALTH CENTER

Provider Business Mailing Address
First Line	:	6035 RIVERS AVE STE A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-5018
Country	:	US
Telephone Number	:	843-572-9909
Fax Number	:

Provider Business Practice Location Address
First Line	:	6035 RIVERS AVE STE A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-5018
Country	:	US
Telephone Number	:	843-572-9909
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DAN SPEARS
Credential	:
Telephone Number	:	843-572-9909

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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