Basic Information
| Provider Information | |||||||||
| NPI: | 1073531968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELZIE MEDLOCK | ||||||||
| FirstName: | CHANDA | ||||||||
| MiddleName: | TRISHAUNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 357 | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299362605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 719 OKATIE HWY # 170 | ||||||||
| Address2: | |||||||||
| City: | OKATIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299093963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 011979 | GA | N | Dental Providers | Dentist | General Practice | 1223G0001X | 4669 | SC | Y | Dental Providers | Dentist | General Practice |
No ID Information.