Healthcare Provider Details

I. General information

NPI: 1396671301
Provider Name (Legal Business Name): SOUTH SHORE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHARTER OAK RD
LEXINGTON SC
29072-9710
US

IV. Provider business mailing address

110 CHARTER OAK RD
LEXINGTON SC
29072-9710
US

V. Phone/Fax

Practice location:
  • Phone: 803-359-6143
  • Fax: 803-359-6140
Mailing address:
  • Phone: 803-359-6143
  • Fax: 803-359-6140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JON DAVID SMITH
Title or Position: CO/OWNER
Credential: DDS
Phone: 803-606-5134