MEDICARE: PALMETTO DENTAL SERVICES

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	3755	SC
2	1223G0001X	General Practice Dentistry	3578	SC

General Provider Information

NPI Number	:	1831156892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO DENTAL SERVICES

Provider Business Mailing Address
First Line	:	1330 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3526
Country	:	US
Telephone Number	:	803-254-1911
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3526
Country	:	US
Telephone Number	:	803-254-1911
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. AKIAYA TANENKA HARRIS
Credential	:
Telephone Number	:	803-254-1911

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	08/12/2010

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