Provider Demographics
NPI:1508004268
Name:GOOSE CREEK FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:GOOSE CREEK FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-764-3081
Mailing Address - Street 1:122 S GOOSE CREEK BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3136
Mailing Address - Country:US
Mailing Address - Phone:843-764-3081
Mailing Address - Fax:843-764-4977
Practice Address - Street 1:122 S GOOSE CREEK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3136
Practice Address - Country:US
Practice Address - Phone:843-764-3081
Practice Address - Fax:843-764-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15601223G0001X
SC43691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty