Healthcare Provider Details

I. General information

NPI: 1528585924
Provider Name (Legal Business Name): CAROLINA ORTHODONTICS AND PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 LONGTOWN RD STE B
COLUMBIA SC
29229-9498
US

IV. Provider business mailing address

PO BOX 854
MOUNT PLEASANT SC
29465-0854
US

V. Phone/Fax

Practice location:
  • Phone: 803-661-8468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS P LEITE
Title or Position: OWNER/PRESIDENT
Credential: DMD, MS
Phone: 843-270-6473