Provider Demographics
NPI:1437437548
Name:TRIDENT GENERAL DENTISTRY, DOUGLAS S RAWLS, DM
Entity Type:Organization
Organization Name:TRIDENT GENERAL DENTISTRY, DOUGLAS S RAWLS, DM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER (SINGLE MEMBER OF LLC)
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAWLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-552-2580
Mailing Address - Street 1:6335 DORCHESTER ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH CARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418
Mailing Address - Country:US
Mailing Address - Phone:843-552-2580
Mailing Address - Fax:843-552-2596
Practice Address - Street 1:6335 DORCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:NORTH CARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418
Practice Address - Country:US
Practice Address - Phone:843-552-2580
Practice Address - Fax:843-552-2596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENT GENERAL DENTISTRY, DOUGLAS S RAWLS, DMD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1823122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCW17307SC1Medicaid