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General Practice >> Dentist >> Dental Providers

Registrant NPI Number: 1407003650

Individual Registrant:
Gender: M
Sole Proprietor

Location and contact information for practice:
Tel: 803-751-6213  Fax: 803-751-6213

Contact information for business:
Tel: 803-751-6213  Fax: 803-751-6886

Registration Information:
NPI: 1407003650
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y1223G0001XDental Providers
General Practice

Legacy codes, insurance codes and state license numbers:



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