Healthcare Provider Details

I. General information

NPI: 1386891463
Provider Name (Legal Business Name): EDISTO DENTAL ASSOCIATES OF SC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 STATION CT STE C
EDISTO ISLAND SC
29438-3020
US

IV. Provider business mailing address

PO BOX 218
EDISTO ISLAND SC
29438-0218
US

V. Phone/Fax

Practice location:
  • Phone: 843-869-3368
  • Fax:
Mailing address:
  • Phone: 843-869-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number2109
License Number StateSC

VIII. Authorized Official

Name: MRS. JULIE CORLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-279-0015