1730467978 NPI number — CHILDREN'S DENTAL CLINIC OF CHARLESTON, LLC

Table of content: (NPI 1730467978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730467978 NPI number — CHILDREN'S DENTAL CLINIC OF CHARLESTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S DENTAL CLINIC OF CHARLESTON, 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:
CHILDREN'S WELLNESS CLINIC
Provider Other Organization Name Type Code:
3
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:
1730467978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 CHURCH ST
Provider Second Line Business Mailing Address:
SUITE 520
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37219-2428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-750-0342
Provider Business Mailing Address Fax Number:
615-986-1705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6035 RIVERS AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-5018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-572-9909
Provider Business Practice Location Address Fax Number:
843-572-9901
Provider Enumeration Date:
07/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
JEANEAN
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
DIRECTOR, LICENSING & CREDENTIALING
Authorized Official Telephone Number:
615-750-0342

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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