MEDICARE: CANE BAY FAMILY DENTISTRY - GOOSE CREEK 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

General Provider Information

NPI Number	:	1497361307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANE BAY FAMILY DENTISTRY - GOOSE CREEK LLC

Provider Business Mailing Address
First Line	:	129 PLANTATION NORTH BLVD
Second Line	:	UNIT D
City	:	GOOSECREEK
State	:	SC
Zip	:	29445
Country	:	US
Telephone Number	:	843-410-4920
Fax Number	:	843-410-4924

Provider Business Practice Location Address
First Line	:	129 PLANTATION NORTH BLVD
Second Line	:	UNIT D
City	:	GOOSECREEK
State	:	SC
Zip	:	29445-2944
Country	:	US
Telephone Number	:	843-410-4920
Fax Number	:	843-410-4924

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MISS TAYLOR DENAE DAVIS
Credential	:
Telephone Number	:	843-352-4454

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	09/17/2020

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