MEDICARE: BELLA VISTA DENTAL, 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	4377	SC

General Provider Information

NPI Number	:	1659763167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLA VISTA DENTAL, LLC

Provider Business Mailing Address
First Line	:	PO BOX 31625
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29608-1625
Country	:	US
Telephone Number	:	864-386-2753
Fax Number	:

Provider Business Practice Location Address
First Line	:	2498 N PLEASANTBURG DR
Second Line	:	SUITE C
City	:	GREENVILLE
State	:	SC
Zip	:	29609-2730
Country	:	US
Telephone Number	:	864-386-2753
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN ALEXANDER KENNEDY JR.
Credential	:	DMD
Telephone Number	:	864-386-2753

Provider Enumeration Date	:	02/21/2015
Last Update Date	:	02/21/2015

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