Healthcare Provider Details

I. General information

NPI: 1275614828
Provider Name (Legal Business Name): BRAD WESLEY NEVILLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 ASHLEY AVE ROOM 544 BSB, DIVISION OF ORAL PATHOLOGY, MUSC
CHARLESTON SC
29425-5070
US

IV. Provider business mailing address

173 ASHLEY AVE ROOM 544 BSB, DIVISION OF ORAL PATHOLOGY, MUSC
CHARLESTON SC
29425-5070
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-4495
  • Fax: 843-792-3697
Mailing address:
  • Phone: 843-792-4495
  • Fax: 843-792-3697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number2375
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: