Provider Demographics
NPI:1730675653
Name:PITT, MICKELLE O'NEA
Entity Type:Individual
Prefix:
First Name:MICKELLE
Middle Name:O'NEA
Last Name:PITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 DEPOT ST APT 308
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2273
Mailing Address - Country:US
Mailing Address - Phone:252-525-8365
Mailing Address - Fax:
Practice Address - Street 1:1121 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1902
Practice Address - Country:US
Practice Address - Phone:803-590-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD9163GD1223G0001X
SC91631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice