Healthcare Provider Details

I. General information

NPI: 1952974602
Provider Name (Legal Business Name): ALEXA CARMICHAEL ASTON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 EAST BROADWAY STREET
JOHNSONVILLE SC
29555-0297
US

IV. Provider business mailing address

PO BOX 297
JOHNSONVILLE SC
29555-0297
US

V. Phone/Fax

Practice location:
  • Phone: 843-386-2833
  • Fax:
Mailing address:
  • Phone: 843-386-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9905
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: