Provider Demographics
NPI:1811197460
Name:MCDONALD, CEDRICK BROWN (DDS)
Entity Type:Individual
Prefix:
First Name:CEDRICK
Middle Name:BROWN
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9787 CHARLOTTE HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-8103
Mailing Address - Country:US
Mailing Address - Phone:803-547-2280
Mailing Address - Fax:
Practice Address - Street 1:9787 CHARLOTTE HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-8103
Practice Address - Country:US
Practice Address - Phone:803-547-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1506321223G0001X
GADN0151481223G0001X
SC43821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4382Medicaid