Healthcare Provider Details

I. General information

NPI: 1033238589
Provider Name (Legal Business Name): CHARLESTON PEDIATRIC DENTISTRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9217 UNIVERSITY BLVD STE 1C
NORTH CHARLESTON SC
29406-9147
US

IV. Provider business mailing address

9217 UNIVERSITY BLVD STE 1C
NORTH CHARLESTON SC
29406-9147
US

V. Phone/Fax

Practice location:
  • Phone: 843-797-5133
  • Fax: 843-797-5865
Mailing address:
  • Phone: 843-797-5133
  • Fax: 843-797-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2638-0358 SC
License Number StateSC

VIII. Authorized Official

Name: LISA BODIFORD
Title or Position: OFFICE MANAGER
Credential:
Phone: 843-797-5133