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General NPI Number Information
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NPI Number | 1033238589
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Entity Type | Organization
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Legal Business Name | CHARLESTON PEDIATRIC DENTISTRY, P.A.
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9217 UNIVERSITY BLVD STE 1C
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9147
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Country | US
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Telephone | 843-797-5133
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Fax | 843-797-5865
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Provider Business Mailing Address
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Address Line | 9217 UNIVERSITY BLVD STE 1C
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9147
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Country | US
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Telephone | 843-797-5133
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Fax | 843-797-5865
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LISA BODIFORD
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Credential |
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Telephone | 843-797-5133
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2638-0358 SC
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License Number State | SC
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