Healthcare Provider Details

I. General information

NPI: 1851345557
Provider Name (Legal Business Name): CHARLES B. MAXWELL, DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 EAST BROADWAY ST.
JOHNSONVILLE SC
29555-0297
US

IV. Provider business mailing address

144 EAST BROADWAY ST. PO BOX 297
JOHNSONVILLE SC
29555-0297
US

V. Phone/Fax

Practice location:
  • Phone: 843-386-2833
  • Fax: 843-386-2279
Mailing address:
  • Phone: 843-386-2833
  • Fax: 843-386-2279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2117
License Number StateSC

VIII. Authorized Official

Name: DR. CHARLES B MAXWELL
Title or Position: OWNER
Credential: DMD
Phone: 843-386-2833