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General NPI Number Information
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NPI Number | 1386761955
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Entity Type | Organization
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Legal Business Name | LADYS ISLAND DENAL CLINIC
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5 PROFESSIONAL VILLAGE CIR
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City | BEAUFORT
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State | SC
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Zip | 29907-1571
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Country | US
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Telephone | 843-521-0808
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Fax | 843-521-0945
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Provider Business Mailing Address
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Address Line | 5 PROFESSIONAL VILLAGE CIR
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City | BEAUFORT
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State | SC
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Zip | 29907-1571
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Country | US
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Telephone | 843-521-0808
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Fax | 843-521-0945
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Authorized Official
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Title or Position | DENTIST
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Name | DR. TRISTAN H GREENWALT
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Credential | DMD
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Telephone | 843-521-0808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3760
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License Number State | SC
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