MEDICARE: SEA ISLAND FAMILY DENISTRY

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	2564	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538259528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEA ISLAND FAMILY DENISTRY

Provider Business Mailing Address
First Line	:	902 COLEMAN BLVD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-4046
Country	:	US
Telephone Number	:	843-884-4340
Fax Number	:	843-884-1703

Provider Business Practice Location Address
First Line	:	902 COLEMAN BLVD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-4046
Country	:	US
Telephone Number	:	843-884-4340
Fax Number	:	843-884-1703

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN CAGLE III
Credential	:	DMD
Telephone Number	:	843-884-4340

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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1417047499 — DR. JOHN NEWTON CAGLE III D.M.D.
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Directions to “SEA ISLAND FAMILY DENISTRY ” Practice Location

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