MEDICARE: SUNSET CHILDREN'S DENTISTRY

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	1223P0221X	Pediatric Dentistry
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1639571607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNSET CHILDREN'S DENTISTRY

Provider Business Mailing Address
First Line	:	5080 SUNSET BLVD
Second Line	:	SUITE B
City	:	LEXINGTON
State	:	SC
Zip	:	29072-7051
Country	:	US
Telephone Number	:	803-807-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	5080 SUNSET BLVD
Second Line	:	SUITE B
City	:	LEXINGTON
State	:	SC
Zip	:	29072-7051
Country	:	US
Telephone Number	:	803-807-2787
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/ OWNER
Name	:	DR. KATHI SAMPLE
Credential	:	DMD
Telephone Number	:	803-807-2787

Provider Enumeration Date	:	09/22/2014
Last Update Date	:	09/22/2014

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