MEDICARE: PERIODONTIC SPECIALISTS BY SOLOMON DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1194576132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIODONTIC SPECIALISTS BY SOLOMON DENTAL LLC

Provider Business Mailing Address
First Line	:	1971 N MAIN ST
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7890
Country	:	US
Telephone Number	:	843-871-0842
Fax Number	:

Provider Business Practice Location Address
First Line	:	7481 NORTHSIDE DR STE A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29420-4282
Country	:	US
Telephone Number	:	843-863-8634
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	ANGIE BAZZLE
Credential	:
Telephone Number	:	843-871-0842

Provider Enumeration Date	:	03/28/2024
Last Update Date	:	03/24/2025

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