1457666471 NPI number — CAROLINA PERIODONTICS & ENDODONTICS LLC

Table of content: KHALIL GLENN (NPI 1699554758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457666471 NPI number — CAROLINA PERIODONTICS & ENDODONTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA PERIODONTICS & ENDODONTICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457666471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 BAYSHORE DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ROCK HILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29732-1569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-327-4444
Provider Business Mailing Address Fax Number:
803-327-4443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 BAYSHORE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-327-4444
Provider Business Practice Location Address Fax Number:
803-327-4443
Provider Enumeration Date:
08/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MATTHEWS
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PERIODONTIST/OWNER
Authorized Official Telephone Number:
803-579-0026

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  DENTAL: 4667 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223E0200X , with the licence number: DENTAL: 4658 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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