Healthcare Provider Details

I. General information

NPI: 1336932870
Provider Name (Legal Business Name): DOMINIQUE BULTSMA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 SAM RITTENBERG BLVD
CHARLESTON SC
29407-4138
US

IV. Provider business mailing address

1565 SAM RITTENBERG BLVD
CHARLESTON SC
29407-4138
US

V. Phone/Fax

Practice location:
  • Phone: 843-642-0074
  • Fax:
Mailing address:
  • Phone: 843-642-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE BULTSMA
Title or Position: OWNER
Credential: MD
Phone: 843-412-9012