MEDICARE: CAROLINA PARK FAMILY DENTISTRY 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
2	122300000X	Dentist

General Provider Information

NPI Number	:	1851906028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA PARK FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	3520 PARK AVENUE BLVD.
Second Line	:	SUITE 100
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7567
Country	:	US
Telephone Number	:	843-654-1918
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 PARK AVENUE BLVD.
Second Line	:	SUITE 100
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-2946
Country	:	US
Telephone Number	:	843-654-1918
Fax Number	:	843-654-1917

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANDREW BELLEBAUM
Credential	:	DMD
Telephone Number	:	843-654-1918

Provider Enumeration Date	:	09/14/2020
Last Update Date	:	03/03/2021

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