=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053083154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIDENT DENTAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2021
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9228 MEDICAL PLAZA DR
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-574-5693
-----------------------------------------------------
Fax | 843-764-4512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 HEALTH PARK DR
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-373-7406
-----------------------------------------------------
Fax | 866-346-1426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GROUP VICE PRESIDENT/AO
-----------------------------------------------------
Name | WILLIAM TEDERICK JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-372-3375
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------