MEDICARE: PALMETTO PROSTHODONTICS, 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	1223P0700X	Prosthodontics	7043	SC

General Provider Information

NPI Number	:	1497146906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO PROSTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	145 WOODRUFF PLACE CIR
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-3672
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 WOODRUFF PLACE CIR
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-3672
Country	:	US
Telephone Number	:	864-757-9433
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JASON MINTON
Credential	:	DMD
Telephone Number	:	864-757-9433

Provider Enumeration Date	:	02/05/2015
Last Update Date	:	02/05/2015

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