MEDICARE: CAROLINA FAMILY DENTISTRY AT LAKE WYLIE

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639539653	OTHER	SC	DENTIST
2	1528635604	OTHER	SC	DENTIST
3	1083818157	OTHER	SC	DENTIST

General Provider Information

NPI Number	:	1629749106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA FAMILY DENTISTRY AT LAKE WYLIE

Provider Business Mailing Address
First Line	:	244 LATITUDE LN STE 103
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-8125
Country	:	US
Telephone Number	:	803-831-2171
Fax Number	:

Provider Business Practice Location Address
First Line	:	244 LATITUDE LN STE 103
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-8125
Country	:	US
Telephone Number	:	803-831-2171
Fax Number	:	803-831-2172

Authorized Official
Title or Position	:	OWNER/ DENTIST
Name	:	DR. VANESSA N. VARGAS
Credential	:	DMD
Telephone Number	:	803-831-2171

Provider Enumeration Date	:	09/23/2021
Last Update Date	:	09/23/2021

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Directions to “CAROLINA FAMILY DENTISTRY AT LAKE WYLIE ” Practice Location

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