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	:	1659220614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONAL OF SOUTH CAROLINA, P.C.

Provider Business Mailing Address
First Line	:	1575 SILVER BLUFF RD
Second Line	:
City	:	AIKEN
State	:	SC
Zip	:	29803-8609
Country	:	US
Telephone Number	:	839-248-2565
Fax Number	:	839-248-2566

Provider Business Practice Location Address
First Line	:	1575 SILVER BLUFF RD
Second Line	:
City	:	AIKEN
State	:	SC
Zip	:	29803-8609
Country	:	US
Telephone Number	:	839-248-2565
Fax Number	:	839-248-2566

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	HILLARY THULL
Credential	:
Telephone Number	:	217-540-8946

Provider Enumeration Date	:	01/23/2026
Last Update Date	:	01/23/2026

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