Healthcare Provider Details

I. General information

NPI: 1710102405
Provider Name (Legal Business Name): LAVONNE KELLY FORE DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 FOLLY RD STE T
CHARLESTON SC
29412-3907
US

IV. Provider business mailing address

915 FOLLY RD STE T
CHARLESTON SC
29412-3907
US

V. Phone/Fax

Practice location:
  • Phone: 843-642-8100
  • Fax: 843-566-0706
Mailing address:
  • Phone: 843-642-8100
  • Fax: 843-566-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9106-981
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: