Healthcare Provider Details

I. General information

NPI: 1497807903
Provider Name (Legal Business Name): COSMETIC & FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 YEAMANS HALL RD
HANAHAN SC
29406
US

IV. Provider business mailing address

1224 YEAMANS HALL RD
HANAHAN SC
29406
US

V. Phone/Fax

Practice location:
  • Phone: 843-554-4545
  • Fax: 843-554-4548
Mailing address:
  • Phone: 843-554-4545
  • Fax: 843-554-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number003636
License Number StateSC

VIII. Authorized Official

Name: DR. JOHN BRADLEY PALLES
Title or Position: PRES OF COSMETIC & FAMILY DENTISTRY
Credential: DMD
Phone: 843-554-4545