Provider Demographics
NPI:1902814841
Name:FANNING, D ALTON JR (DMD)
Entity Type:Individual
Prefix:
First Name:D
Middle Name:ALTON
Last Name:FANNING
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 1:1264 RIBAUT ROAD
Mailing Address - Street 2:STE 401
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902
Mailing Address - Country:US
Mailing Address - Phone:843-524-7950
Mailing Address - Fax:843-525-1151
Practice Address - Street 1:1264 RIBAUT ROAD
Practice Address - Street 2:STE 401
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-524-7950
Practice Address - Fax:843-525-1151
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC3162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9748Medicaid
783979OtherUNITED CONCORDIA