MEDICARE: LIVE OAK ENDONTICS

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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1598457715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE OAK ENDONTICS

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	:	2080 ROYLE RD UNIT D
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-1301
Country	:	US
Telephone Number	:	843-871-0842
Fax Number	:

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

Provider Enumeration Date	:	05/25/2023
Last Update Date	:	05/25/2023

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Directions to “LIVE OAK ENDONTICS ” Practice Location

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