Provider Demographics
NPI:1255491692
Name:DOLES, LON R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LON
Middle Name:R
Last Name:DOLES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 COSGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-7644
Mailing Address - Country:US
Mailing Address - Phone:843-554-5003
Mailing Address - Fax:843-745-0003
Practice Address - Street 1:2320 COSGROVE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7644
Practice Address - Country:US
Practice Address - Phone:843-554-5003
Practice Address - Fax:843-745-0003
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1927174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC832713OtherUNITED CONCORDIA GROUP
SCZ19276Medicaid