Healthcare Provider Details

I. General information

NPI: 1851906028
Provider Name (Legal Business Name): CAROLINA PARK FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 03/03/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 PARK AVENUE BLVD. SUITE 100
MOUNT PLEASANT SC
29466-2946
US

IV. Provider business mailing address

3520 PARK AVENUE BLVD. SUITE 100
MOUNT PLEASANT SC
29466-7567
US

V. Phone/Fax

Practice location:
  • Phone: 843-654-1918
  • Fax: 843-654-1917
Mailing address:
  • Phone: 843-654-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW BELLEBAUM
Title or Position: OWNER
Credential: DMD
Phone: 843-654-1918