Provider Demographics
NPI:1073162053
Name:SOUTHERN CHARM PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTHERN CHARM PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-441-4757
Mailing Address - Street 1:1305 WAYNEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6907
Mailing Address - Country:US
Mailing Address - Phone:562-441-4757
Mailing Address - Fax:
Practice Address - Street 1:2021 BRIDGEMILL RD.
Practice Address - Street 2:SUITE 108
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-2817
Practice Address - Country:US
Practice Address - Phone:562-441-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty