Provider Demographics
NPI:1568420859
Name:PRATT, SAMUEL NEWTON JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:NEWTON
Last Name:PRATT
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3726
Mailing Address - Country:US
Mailing Address - Phone:843-761-8142
Mailing Address - Fax:843-761-1690
Practice Address - Street 1:219 1ST ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3726
Practice Address - Country:US
Practice Address - Phone:843-761-8142
Practice Address - Fax:843-761-1690
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30-28191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ28195Medicaid