Healthcare Provider Details

I. General information

NPI: 1245052729
Provider Name (Legal Business Name): SFD NORTH CHARLESTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7481 NORTHSIDE DR
NORTH CHARLESTON SC
29420-4282
US

IV. Provider business mailing address

1971 N MAIN ST
SUMMERVILLE SC
29486-7890
US

V. Phone/Fax

Practice location:
  • Phone: 843-871-0842
  • Fax:
Mailing address:
  • Phone: 843-871-0842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGIE BAZZLE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 843-871-0842