MEDICARE: GRAND STRAND PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry	3125	SC
2	1223P0221X	Pediatric Dentistry	3125SC	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881800480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND STRAND PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	3112 DICK POND ROAD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-4833
Country	:	US
Telephone Number	:	843-294-5437
Fax Number	:	843-294-5440

Provider Business Practice Location Address
First Line	:	3112 DICK POND ROAD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-4833
Country	:	US
Telephone Number	:	843-294-5437
Fax Number	:	843-294-5440

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WINONA M NEWMAN
Credential	:	DMD
Telephone Number	:	843-294-5437

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	03/03/2010

Similar Medicare Providers

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Practice Location Address:

3112 DICK POND ROAD
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Practice Location Address:

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1841240330 — DON L STROMQUIST M.D.
Practice Location Address:

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1558399477 — MARY E DING FNP
Practice Location Address:

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1134273485 — UTAH ARTHRITIS CLINIC PC
Practice Location Address:

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