MEDICARE: FOREST ACRES DENTAL CARE, P.A.

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	3327	SC

General Provider Information

NPI Number	:	1780879247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREST ACRES DENTAL CARE, P.A.

Provider Business Mailing Address
First Line	:	PO BOX 6468
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29260-6468
Country	:	US
Telephone Number	:	803-782-8786
Fax Number	:	803-782-6682

Provider Business Practice Location Address
First Line	:	5101 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29206-4962
Country	:	US
Telephone Number	:	803-782-8786
Fax Number	:	803-782-6682

Authorized Official
Title or Position	:	OWNER
Name	:	DR. M. CAROLINE JONES GUTIERREZ
Credential	:	D.M.D.
Telephone Number	:	803-782-8786

Provider Enumeration Date	:	09/07/2007
Last Update Date	:	10/18/2010

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