Healthcare Provider Details

I. General information

NPI: 1730633363
Provider Name (Legal Business Name): SAMANTHA MIZE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BEE ST
CHARLESTON SC
29425-0001
US

IV. Provider business mailing address

2053 CHILHOWEE DR
JOHNS ISLAND SC
29455-8198
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32158
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: