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General NPI Number Information
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NPI Number | 1710389879
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Entity Type | Organization
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Legal Business Name | SMILEOLOGY ECO DENTAL SPA PC
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Dates
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Enumeration Date | 09/19/2014
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Last Update Date | 10/15/2014
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Provider Practice Location Address
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Address Line | 2106 MOUNT PLEASANT ST # P-137
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City | CHARLESTON
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State | SC
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Zip | 29403-3026
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Country | US
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Telephone | 843-608-3188
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Fax |
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Provider Business Mailing Address
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Address Line | 6518 DORCHESTER RD SUITE A
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City | NORTH CHARLESTON
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State | SC
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Zip | 29418-5100
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Country | US
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Telephone | 843-767-8555
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. TRACY PAGE
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Credential | DDS
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Telephone | 404-862-2004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 4691
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License Number State | SC
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