MEDICARE: DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.

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	:	1578034369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.

Provider Business Mailing Address
First Line	:	2373 LEN PATTERSON RD STE 103
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8266
Country	:	US
Telephone Number	:	803-752-0655
Fax Number	:	803-396-0029

Provider Business Practice Location Address
First Line	:	2373 LEN PATTERSON RD STE 103
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8266
Country	:	US
Telephone Number	:	803-310-6109
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	JESSICA BRITT
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	12/06/2018
Last Update Date	:	03/29/2019

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