=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346925781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLESTON ORAL MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2023
-----------------------------------------------------
Last Update Date | 06/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 INGLESIDE BLVD STE 101
-----------------------------------------------------
City | LADSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29456-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-762-9028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 INGLESIDE BLVD STE 101
-----------------------------------------------------
City | LADSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29456-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-762-9028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | MRS. LYNDA TYLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-974-5236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------