MEDICARE: BELA FAMILY DENTISTRY OF WHITE KNOLL

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	4708	SC

General Provider Information

NPI Number	:	1457712143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELA FAMILY DENTISTRY OF WHITE KNOLL

Provider Business Mailing Address
First Line	:	PO BOX 1557
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29071-1557
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1915 SOUTHLAKE DR.
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073
Country	:	US
Telephone Number	:	803-479-1795
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW COOK
Credential	:
Telephone Number	:	803-479-1795

Provider Enumeration Date	:	03/09/2016
Last Update Date	:	06/23/2021

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