Provider Demographics
NPI:1174207856
Name:CALVERT, NATHANIEL TAYLOR
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:TAYLOR
Last Name:CALVERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 PHEASANT WAY
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-8307
Mailing Address - Country:US
Mailing Address - Phone:864-908-6351
Mailing Address - Fax:
Practice Address - Street 1:3369 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4105
Practice Address - Country:US
Practice Address - Phone:864-297-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.10537122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist