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General NPI Number Information
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NPI Number | 1447040431
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Entity Type | Organization
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Legal Business Name | FORTH DENTAL CHARLESTON, LLC
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Dates
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Enumeration Date | 05/12/2025
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 454 CLEMSON RD
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City | COLUMBIA
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State | SC
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Zip | 29229-7925
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Country | US
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Telephone | 34-623-6628
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Fax | 803-619-6053
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Provider Business Mailing Address
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Address Line | 454 CLEMSON RD
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City | COLUMBIA
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State | SC
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Zip | 29229-7925
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Country | US
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Telephone | 34-623-6628
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Fax | 803-619-6053
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | DEENA MARIE PHIMVONGSA
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Credential | OPERATIONAL MANAGER
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Telephone | 702-354-4569
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number |
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License Number State |
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