NPIMap

Organization Active NPI

Lake Wylie Family Dentistry PA

  • Dentist
  • Lake Wylie, SC
National Provider Identifier
1437370798
Registry record updated Feb 4, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
2830 Issued in SC
Legal business name
LAKE WYLIE FAMILY DENTISTRY PA
Practice address
1100 Village Harbor Dr
Lake Wylie, SC 29710
Phone
(803) 831-8856
Fax
(803) 831-8966
NPI assigned
May 2, 2007
Last updated
Feb 4, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 4, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Susan M Stall
Title
Insurance Dept
Phone
(803) 831-8856

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 2830 SC Primary
Dentist 122300000X 3673 SC

Addresses

Primary practice location

1100 Village Harbor Dr
Lake Wylie, SC 29710

Mailing address

PO Box 5248
Lake Wylie, SC 29710
Phone (803) 831-8856

Other names 1

  • Dr Thomas N Stall DMD or Dr Stacy L Blackmon DDS Other name

National Provider Directory

National Provider Directory

Locations

1100 Village Harbor Dr
Lake Wylie, SC 29710
Phone (803) 831-8856

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178064000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1202083200000",
    "number": "1437370798",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5248",
            "city": "LAKE WYLIE",
            "state": "SC",
            "postal_code": "29710",
            "telephone_number": "803-831-8856",
            "fax_number": "803-831-8966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 VILLAGE HARBOR DR",
            "city": "LAKE WYLIE",
            "state": "SC",
            "postal_code": "29710",
            "telephone_number": "803-831-8856",
            "fax_number": "803-831-8966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE WYLIE FAMILY DENTISTRY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-02",
        "last_updated": "2008-02-04",
        "status": "A",
        "authorized_official_last_name": "STALL",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "INSURANCE DEPT",
        "authorized_official_telephone_number": "803-831-8856",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "SC",
            "license": "2830",
            "primary": true
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "SC",
            "license": "3673",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dr Thomas N Stall DMD or Dr Stacy L Blackmon DDS",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Lake Wylie, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.