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General NPI Number Information
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NPI Number | 1598088312
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Entity Type | Organization
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Legal Business Name | WENTWORTH STREET DENTAL ASSOCIATES, INC
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Dates
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Enumeration Date | 03/08/2010
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Last Update Date | 03/08/2010
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Provider Practice Location Address
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Address Line | 159 WENTWORTH ST
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City | CHARLESTON
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State | SC
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Zip | 29401-6715
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Country | US
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Telephone | 843-577-2898
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Fax | 843-577-4464
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Provider Business Mailing Address
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Address Line | 159 WENTWORTH ST
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City | CHARLESTON
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State | SC
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Zip | 29401-6715
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Country | US
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Telephone | 843-577-2898
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Fax | 843-577-4464
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Authorized Official
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Title or Position | C.E.O.
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Name | DR. ROGERS CONYERS REEVES
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Credential | D.M.D.
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Telephone | 843-577-2898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 1547
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License Number State | SC
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