Healthcare Provider Details

I. General information

NPI: 1508924705
Provider Name (Legal Business Name): CAROLINA ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 STONEMARK LANE
COLUMBIA SC
29210-3841
US

IV. Provider business mailing address

130 STONEMARK LANE
COLUMBIA SC
29210-3841
US

V. Phone/Fax

Practice location:
  • Phone: 803-798-8476
  • Fax: 803-798-6451
Mailing address:
  • Phone: 803-798-8476
  • Fax: 803-798-6451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT JAY GOHEAN
Title or Position: PRESIDENT
Credential: DMD
Phone: 803-798-8476