Provider Demographics
NPI:1205997921
Name:DECKER, JAMES R (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:DECKER
Suffix:
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 1:109 WAPPOO CREEK DR
Mailing Address - Street 2:4A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2135
Mailing Address - Country:US
Mailing Address - Phone:843-795-0231
Mailing Address - Fax:843-795-0223
Practice Address - Street 1:109 WAPPOO CREEK DR
Practice Address - Street 2:4A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2135
Practice Address - Country:US
Practice Address - Phone:843-795-0231
Practice Address - Fax:843-795-0223
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ21012Medicaid