Provider Demographics
NPI:1003955659
Name:CHARLESTON PERIODONTICSPA
Entity Type:Organization
Organization Name:CHARLESTON PERIODONTICSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LARO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MHS
Authorized Official - Phone:843-766-7131
Mailing Address - Street 1:1051 GARDNER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5747
Mailing Address - Country:US
Mailing Address - Phone:843-766-7131
Mailing Address - Fax:843-766-1839
Practice Address - Street 1:1051 GARDNER RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5747
Practice Address - Country:US
Practice Address - Phone:843-766-7131
Practice Address - Fax:843-766-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty