MEDICARE: TGD-WEST ASHLEY 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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		NA

General Provider Information

NPI Number	:	1629691449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TGD-WEST ASHLEY LLC

Provider Business Mailing Address
First Line	:	2048 SAM RITTENBERG BLVD STE 2
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-4673
Country	:	US
Telephone Number	:	843-556-5150
Fax Number	:

Provider Business Practice Location Address
First Line	:	2048 SAM RITTENBERG BLVD STE 2
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-4673
Country	:	US
Telephone Number	:	843-556-5150
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ERIC LAYTON
Credential	:	DDS
Telephone Number	:	843-552-2580

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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