Provider Demographics
NPI:1003033192
Name:TATUM, MARY VICTORIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:VICTORIA
Last Name:TATUM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 COURTENAY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5742
Mailing Address - Country:US
Mailing Address - Phone:843-577-6112
Mailing Address - Fax:843-937-0200
Practice Address - Street 1:92 COURTENAY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5742
Practice Address - Country:US
Practice Address - Phone:843-577-6112
Practice Address - Fax:843-937-0200
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice