Healthcare Provider Details

I. General information

NPI: 1497721955
Provider Name (Legal Business Name): JOHAN I KOLMODIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 TANNER FORD BLVD SUITE 102
HANAHAN SC
29410
US

IV. Provider business mailing address

1005 TANNER FORD BLVD SUITE 102
HANAHAN SC
29410
US

V. Phone/Fax

Practice location:
  • Phone: 843-797-6287
  • Fax: 843-797-6292
Mailing address:
  • Phone: 843-797-6287
  • Fax: 843-797-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3436
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: