Healthcare Provider Details

I. General information

NPI: 1639593254
Provider Name (Legal Business Name): MEDICAL UNIVERSITY OF SOUTH CAROLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 ASHLEY AVE
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-4496
  • Fax:
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-3911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: THERESA GONZALES
Title or Position: DIRECTOR
Credential: DMD
Phone: 843-792-4496