Healthcare Provider Details

I. General information

NPI: 1710442967
Provider Name (Legal Business Name): CENTRAL CAROLINA ENDODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 COOK ROAD
ORANGEBURG SC
29118
US

IV. Provider business mailing address

888 COOK ROAD
ORANGEBURG SC
29118
US

V. Phone/Fax

Practice location:
  • Phone: 803-516-0777
  • Fax: 803-516-0577
Mailing address:
  • Phone: 803-516-0777
  • Fax: 803-516-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH DAVIN BONAVILLA
Title or Position: PRESIDENT
Credential: DDS
Phone: 803-516-0777