Provider Demographics
NPI:1346925781
Name:CHARLESTON ORAL MEDICINE, LLC
Entity Type:Organization
Organization Name:CHARLESTON ORAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-974-5236
Mailing Address - Street 1:3700 INGLESIDE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4141
Mailing Address - Country:US
Mailing Address - Phone:843-762-9028
Mailing Address - Fax:
Practice Address - Street 1:3700 INGLESIDE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4141
Practice Address - Country:US
Practice Address - Phone:843-762-9028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental