Provider Demographics
NPI:1316612054
Name:COTTEN, CARLY VAIL (DMD)
Entity type:Individual
Prefix:DR
First Name:CARLY
Middle Name:VAIL
Last Name:COTTEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GERVAIS ST APT 201
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3097
Mailing Address - Country:US
Mailing Address - Phone:251-550-7060
Mailing Address - Fax:
Practice Address - Street 1:7701 TRENHOLM ROAD EXT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1725
Practice Address - Country:US
Practice Address - Phone:803-736-6000
Practice Address - Fax:803-736-6084
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRP23691223P0221X
SC10649PD1223P0221X
SC104741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry