Healthcare Provider Details

I. General information

NPI: 1376809772
Provider Name (Legal Business Name): ROSS ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 CADUCEUS DR
MYRTLE BEACH SC
29588-2902
US

IV. Provider business mailing address

3508 CADUCEUS DR
MYRTLE BEACH SC
29588-2902
US

V. Phone/Fax

Practice location:
  • Phone: 843-293-3522
  • Fax: 843-293-0973
Mailing address:
  • Phone: 843-293-3522
  • Fax: 843-293-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4318
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MICHAEL R MUNN
Title or Position: ORTHODONTIST
Credential: DMD,MS
Phone: 843-293-3522