=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144685330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAMBLE DENTALSMART PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2015
-----------------------------------------------------
Last Update Date | 04/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4921 CENTRE POINTE DR SUITE 201
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29418-6996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-735-6727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 SAVANNAH HWY
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-735-6727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRIAN SCHLEIFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-735-6727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1626
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------