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General NPI Number Information
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NPI Number | 1790512655
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Entity Type | Organization
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Legal Business Name | BLACK MYRTLE ENDODONTICS, LLC
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Dates
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Enumeration Date | 09/16/2024
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Last Update Date | 09/16/2024
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Provider Practice Location Address
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Address Line | 4610 OLEANDER DR STE 201
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City | MYRTLE BEACH
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State | SC
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Zip | 29577-5752
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Country | US
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Telephone | 843-492-6724
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Fax |
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Provider Business Mailing Address
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Address Line | 4610 OLEANDER DR STE 201
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City | MYRTLE BEACH
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State | SC
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Zip | 29577-5752
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTIAN BLACK
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Credential | DMD, MSD
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Telephone | 843-492-6724
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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