Provider Demographics
NPI:1003016437
Name:MOBILE DENTAL CARE LLC
Entity Type:Organization
Organization Name:MOBILE DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-766-6194
Mailing Address - Street 1:1064 GARDNER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5768
Mailing Address - Country:US
Mailing Address - Phone:843-766-6194
Mailing Address - Fax:
Practice Address - Street 1:1064 GARDNER RD
Practice Address - Street 2:STE 101
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5768
Practice Address - Country:US
Practice Address - Phone:843-766-6194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC36541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9562Medicaid