Healthcare Provider Details

I. General information

NPI: 1023180528
Provider Name (Legal Business Name): ELLIS OAKS DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 DANIEL ELLIS DRIVE SUITE 3A
CHARLESTON SC
29412
US

IV. Provider business mailing address

PO BX 12290
CHARLESTON SC
29422-2290
US

V. Phone/Fax

Practice location:
  • Phone: 843-762-2065
  • Fax: 843-762-7735
Mailing address:
  • Phone: 843-762-2065
  • Fax: 843-762-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2406
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2406
License Number StateSC

VIII. Authorized Official

Name: MRS. TERESA E WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 843-762-2065