Provider Demographics
NPI:1861498180
Name:DEPAUL, EDNA KLATT (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:KLATT
Last Name:DEPAUL
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 1:701 LEADER LN
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8152
Mailing Address - Country:US
Mailing Address - Phone:843-345-2307
Mailing Address - Fax:843-881-3161
Practice Address - Street 1:701 LEADER LN
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8152
Practice Address - Country:US
Practice Address - Phone:843-345-2307
Practice Address - Fax:843-881-3161
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC992529Medicaid
SC2529OtherSC DENTAL LICENCE
SC488297OtherUNITED CONCORDIA INS CO