MEDICARE: FAMILY LASER DENTAL OF NORTH CHARLESTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8812	SC

General Provider Information

NPI Number	:	1275070070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY LASER DENTAL OF NORTH CHARLESTON

Provider Business Mailing Address
First Line	:	4245 COOLIDGE ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7161
Country	:	US
Telephone Number	:	603-236-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	7455 CROSS COUNTY RD
Second Line	:	UNIT 5
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-8470
Country	:	US
Telephone Number	:	843-552-4771
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. DAVID IENI
Credential	:	DDS
Telephone Number	:	603-236-9770

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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