=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245113356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORDING ISLAND DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2025
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 OKATIE VILLAGE DR SUITE 4
-----------------------------------------------------
City | OKATIE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-489-8463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 CANOPY COURT
-----------------------------------------------------
City | OKATIE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-489-8463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PAYOR CONTRACTS
-----------------------------------------------------
Name | CASEY CASTLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-732-1504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------