Healthcare Provider Details

I. General information

NPI: 1346925781
Provider Name (Legal Business Name): CHARLESTON ORAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 INGLESIDE BLVD STE 101
LADSON SC
29456-4141
US

IV. Provider business mailing address

3700 INGLESIDE BLVD STE 101
LADSON SC
29456-4141
US

V. Phone/Fax

Practice location:
  • Phone: 843-762-9028
  • Fax:
Mailing address:
  • Phone: 843-762-9028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LYNDA TYLER
Title or Position: CONTROLLER
Credential:
Phone: 843-974-5236