MEDICARE: SFD MT. PLEASANT 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	1223P0221X	Pediatric Dentistry
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457994196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SFD MT. PLEASANT LLC

Provider Business Mailing Address
First Line	:	1971 N MAIN ST
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7890
Country	:	US
Telephone Number	:	843-871-0842
Fax Number	:

Provider Business Practice Location Address
First Line	:	3102 N HIGHWAY 17
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-6925
Country	:	US
Telephone Number	:	843-871-0842
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	ANGELA E BAZZLE
Credential	:
Telephone Number	:	843-871-0842

Provider Enumeration Date	:	10/25/2019
Last Update Date	:	02/04/2021

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