Healthcare Provider Details

I. General information

NPI: 1114677077
Provider Name (Legal Business Name): SMILE CAROLINA DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 W COLEMAN BLVD
MOUNT PLEASANT SC
29464-3437
US

IV. Provider business mailing address

434 W COLEMAN BLVD
MOUNT PLEASANT SC
29464-3437
US

V. Phone/Fax

Practice location:
  • Phone: 843-884-8884
  • Fax: 843-856-0112
Mailing address:
  • Phone: 843-884-8884
  • Fax: 843-856-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY JOHNSON
Title or Position: OWNER
Credential: DMD
Phone: 843-884-8884