MEDICARE: LADYS ISLAND DENAL CLINIC

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	122300000X	Dentist	3760	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	923437	OTHER	SC	UNITED CONCORDIA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	970484	OTHER	SC	UNITED CONCORDIA

General Provider Information

NPI Number	:	1386761955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LADYS ISLAND DENAL CLINIC

Provider Business Mailing Address
First Line	:	5 PROFESSIONAL VILLAGE CIR
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29907-1571
Country	:	US
Telephone Number	:	843-521-0808
Fax Number	:	843-521-0945

Provider Business Practice Location Address
First Line	:	5 PROFESSIONAL VILLAGE CIR
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29907-1571
Country	:	US
Telephone Number	:	843-521-0808
Fax Number	:	843-521-0945

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. TRISTAN H GREENWALT
Credential	:	DMD
Telephone Number	:	843-521-0808

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	08/22/2020

Similar Medicare Providers

1518940980 — DR. TRISTAN GREENWALT DMD
Practice Location Address:

5 PROFESSIONAL VILLAGE CIR
BEAUFORT, SC
29907-1571

Practice Phone: 843-521-0808
Practice Fax: 843-521-0945

1386762342 — DR. ANGELA L LITCHFIELD DMD
Practice Location Address:

5 PROFESSIONAL VILLAGE CIR
BEAUFORT, SC
29907-1571

Practice Phone: 843-521-0808
Practice Fax: 843-521-0945

1578568259 — THOMAS JAMES DOWNS MD
Practice Location Address:

44 SHEFFIELD AVE
BEAUFORT, SC
29907-1753

Practice Phone: 843-522-6862
Practice Fax:

1043216237 — DR. PETER MICHAEL MURPHY DDS, MS
Practice Location Address:

10 PROFESSIONAL VILLAGE CIR
BEAUFORT, SC
29907-1569

Practice Phone: 843-770-9904
Practice Fax: 843-770-9906

1912998204 — HENRY LUCIUS LAFFITTE JR. MD
Practice Location Address:

10B KEMMERLIN LANE
BEAUFORT, SC
29907-2702

Practice Phone: 843-322-8477
Practice Fax: 843-322-8077

1255315024 — MRS. JULIA B HETHERINGTON MHS OTR CHT
Practice Location Address:

18 PROFESSIONAL VILLAGE CIRCLE
BEAUFORT, SC
29907

Practice Phone: 843-521-9673
Practice Fax: 843-986-9369

Directions to “LADYS ISLAND DENAL CLINIC ” Practice Location

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