MEDICARE: MIDLANDS FAMILY DENTISTRY

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	SC2345	SC

General Provider Information

NPI Number	:	1346406733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLANDS FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	2844 SUNSET BLVD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3420
Country	:	US
Telephone Number	:	803-731-0803
Fax Number	:

Provider Business Practice Location Address
First Line	:	2844 SUNSET BLVD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3420
Country	:	US
Telephone Number	:	803-731-0803
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LARRY D RICKBORN
Credential	:	DMD
Telephone Number	:	803-731-0803

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	08/05/2008

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Directions to “MIDLANDS FAMILY DENTISTRY ” Practice Location

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