Healthcare Provider Details

I. General information

NPI: 1811632029
Provider Name (Legal Business Name): CHARLESTON IMPLANT & SEDATION DENTISTRY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 S GOOSE CREEK BLVD STE D
GOOSE CREEK SC
29445-3136
US

IV. Provider business mailing address

122A S GOOSE CREEK BLVD
GOOSE CREEK SC
29445-3136
US

V. Phone/Fax

Practice location:
  • Phone: 843-501-1965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RYAN N. GILREATH
Title or Position: OWNER
Credential:
Phone: 843-810-0109