Healthcare Provider Details

I. General information

NPI: 1043763212
Provider Name (Legal Business Name): BROCKMAN DAVIS SMITH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 SAINT ANDREWS BLVD
CHARLESTON SC
29407-7164
US

IV. Provider business mailing address

753 SAINT ANDREWS BLVD
CHARLESTON SC
29407-7164
US

V. Phone/Fax

Practice location:
  • Phone: 843-571-6371
  • Fax:
Mailing address:
  • Phone: 843-571-6371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number8747
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: