Provider Demographics
NPI:1215155817
Name:MALTEZOS, MARY BELL (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:BELL
Last Name:MALTEZOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3931 COLONEL VANDERHORST CIR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8035
Mailing Address - Country:US
Mailing Address - Phone:843-884-9137
Mailing Address - Fax:
Practice Address - Street 1:3070 N HIGHWAY 17 STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9300
Practice Address - Country:US
Practice Address - Phone:843-849-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3972Medicaid