Provider Demographics
NPI:1497807903
Name:COSMETIC & FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:COSMETIC & FAMILY DENTISTRY PC
Other - Org Name:JOHN BRADLEY PALLES DMD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRES OF COSMETIC & FAMILY DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:PALLES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-554-4545
Mailing Address - Street 1:1224 YEAMANS HALL RD
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-554-4545
Mailing Address - Fax:843-554-4548
Practice Address - Street 1:1224 YEAMANS HALL RD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-554-4545
Practice Address - Fax:843-554-4548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0036361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3636Medicaid