MEDICARE: DR. ABDALLAH K IFRAITEKH DMD

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	122300000X	Dentist	8291	SC

General Provider Information

NPI Number	:	1679909022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ABDALLAH K IFRAITEKH DMD

Provider Business Mailing Address
First Line	:	131 HARBISON BLVD
Second Line	:	SUITE G
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2226
Country	:	US
Telephone Number	:	803-661-9529
Fax Number	:	803-661-9783

Provider Business Practice Location Address
First Line	:	131 HARBISON BLVD
Second Line	:	SUITE G
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2226
Country	:	US
Telephone Number	:	803-661-9529
Fax Number	:	803-661-9783

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2013
Last Update Date	:	09/17/2013

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