MEDICARE: DR. JOHAN I KOLMODIN DMD

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	3436	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	963368	OTHER	GA	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	817149	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1497721955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHAN I KOLMODIN DMD

Provider Business Mailing Address
First Line	:	1005 TANNER FORD BLVD
Second Line	:	SUITE 102
City	:	HANAHAN
State	:	SC
Zip	:	29410
Country	:	US
Telephone Number	:	843-797-6287
Fax Number	:	843-797-6292

Provider Business Practice Location Address
First Line	:	1005 TANNER FORD BLVD
Second Line	:	SUITE 102
City	:	HANAHAN
State	:	SC
Zip	:	29410
Country	:	US
Telephone Number	:	843-797-6287
Fax Number	:	843-797-6292

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	02/03/2009

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