Provider Demographics
NPI:1497721955
Name:KOLMODIN, JOHAN I (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHAN
Middle Name:I
Last Name:KOLMODIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 TANNER FORD BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410
Mailing Address - Country:US
Mailing Address - Phone:843-797-6287
Mailing Address - Fax:843-797-6292
Practice Address - Street 1:1005 TANNER FORD BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410
Practice Address - Country:US
Practice Address - Phone:843-797-6287
Practice Address - Fax:843-797-6292
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA963368OtherBLUE CROSS
SCZ34368Medicaid
817149OtherUNITED CONCORDIA