MEDICARE: CHILDREN'S DENTAL CLINIC OF CHARLESTON, 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	363L00000X	Nurse Practitioner	N/A

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	:	1730467978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTAL CLINIC OF CHARLESTON, LLC

Provider Business Mailing Address
First Line	:	618 CHURCH ST
Second Line	:	SUITE 520
City	:	NASHVILLE
State	:	TN
Zip	:	37219-2428
Country	:	US
Telephone Number	:	615-750-0342
Fax Number	:	615-986-1705

Provider Business Practice Location Address
First Line	:	6035 RIVERS AVE STE A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-5018
Country	:	US
Telephone Number	:	843-572-9909
Fax Number	:	843-572-9901

Authorized Official
Title or Position	:	DIRECTOR, LICENSING & CREDENTIALING
Name	:	MRS. JEANEAN S. FOSTER
Credential	:
Telephone Number	:	615-750-0342

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/21/2011

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