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General NPI Number Information
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NPI Number | 1902345630
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Entity Type | Organization
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Legal Business Name | SMILE ON CHARLESTON, LLC
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 02/14/2017
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Provider Practice Location Address
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Address Line | 91 RUTLEDGE AVE
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City | CHARLESTON
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State | SC
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Zip | 29401-1722
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Country | US
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Telephone | 843-577-7477
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Fax |
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Provider Business Mailing Address
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Address Line | 91 RUTLEDGE AVE
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City | CHARLESTON
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State | SC
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Zip | 29401-1722
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Country | US
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Telephone | 843-577-7477
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | CANDIE S GOODWIN
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Credential |
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Telephone | 704-892-3300
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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 | 8066
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License Number State | SC
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