MEDICARE: DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.

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

General Provider Information

NPI Number	:	1952182149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.

Provider Business Mailing Address
First Line	:	101 HIGHWAY 17 S
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3117
Country	:	US
Telephone Number	:	843-492-5861
Fax Number	:	843-492-5829

Provider Business Practice Location Address
First Line	:	101 HIGHWAY 17 S
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3117
Country	:	US
Telephone Number	:	843-492-5861
Fax Number	:	843-492-5829

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	BELINDA HUERTA
Credential	:
Telephone Number	:	217-540-2100

Provider Enumeration Date	:	10/12/2023
Last Update Date	:	10/12/2023

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