Healthcare Provider Details

I. General information

NPI: 1275070070
Provider Name (Legal Business Name): FAMILY LASER DENTAL OF NORTH CHARLESTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 CROSS COUNTY RD UNIT 5
NORTH CHARLESTON SC
29418-8470
US

IV. Provider business mailing address

4245 COOLIDGE ST
MOUNT PLEASANT SC
29466-7161
US

V. Phone/Fax

Practice location:
  • Phone: 843-552-4771
  • Fax:
Mailing address:
  • Phone: 603-236-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8812
License Number StateSC

VIII. Authorized Official

Name: DR. DAVID IENI
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 603-236-9770