MEDICARE: MARLA T MCMAHON DMD 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	3332	SC

General Provider Information

NPI Number	:	1710005574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARLA T MCMAHON DMD LLC

Provider Business Mailing Address
First Line	:	198 RUTLEDGE AVE
Second Line	:	#3
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5817
Country	:	US
Telephone Number	:	843-723-5405
Fax Number	:

Provider Business Practice Location Address
First Line	:	198 RUTLEDGE AVE
Second Line	:	#3
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5817
Country	:	US
Telephone Number	:	843-723-5405
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST PRACTICE OWNER
Name	:	MARLA TERESA MCMAHON
Credential	:	DMD
Telephone Number	:	843-723-5405

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	04/07/2016

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