MEDICARE: SOUTHLAKE FAMILY DENTISTRY 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	1223G0001X	General Practice Dentistry	3549	SC
2	1223G0001X	General Practice Dentistry	2588	SC

General Provider Information

NPI Number	:	1487670667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAKE FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	1741 GOLD HILL RD
Second Line	:	SUITE 2010
City	:	FORT MILL
State	:	SC
Zip	:	29708-8202
Country	:	US
Telephone Number	:	803-548-3342
Fax Number	:	803-548-3817

Provider Business Practice Location Address
First Line	:	1741 GOLD HILL RD
Second Line	:	SUITE 2010
City	:	FORT MILL
State	:	SC
Zip	:	29708-8202
Country	:	US
Telephone Number	:	803-548-3342
Fax Number	:	803-548-3817

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY C KIMSEY
Credential	:	D.M.D.,F.A.G.D.
Telephone Number	:	803-548-3342

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/16/2007

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