Provider Demographics
NPI:1326166240
Name:MUSCDENTAL FACULTY PRACTICE
Entity Type:Organization
Organization Name:MUSCDENTAL FACULTY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACKLOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-792-8330
Mailing Address - Street 1:173 ASHLEY AVE
Mailing Address - Street 2:BSB 346
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-0001
Mailing Address - Country:US
Mailing Address - Phone:843-792-3444
Mailing Address - Fax:843-792-0348
Practice Address - Street 1:173 ASHLEY AVE
Practice Address - Street 2:BSB 346
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-792-3444
Practice Address - Fax:843-792-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty