Provider Demographics
NPI:1275764672
Name:SUMMERVILLE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SUMMERVILLE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PC
Authorized Official - Phone:873-871-6433
Mailing Address - Street 1:405 W 5TH NORTH ST STE A
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6515
Mailing Address - Country:US
Mailing Address - Phone:843-871-6433
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH NORTH ST STE A
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6515
Practice Address - Country:US
Practice Address - Phone:843-871-6433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty