Provider Demographics
NPI:1609814573
Name:RAWLS, DOUGLAS SULLIVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:SULLIVAN
Last Name:RAWLS
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 1:6335 DORCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-5103
Mailing Address - Country:US
Mailing Address - Phone:843-552-2580
Mailing Address - Fax:843-552-2596
Practice Address - Street 1:6335 DORCHESTER RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-5103
Practice Address - Country:US
Practice Address - Phone:843-552-2580
Practice Address - Fax:843-552-2596
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9589Medicaid
SCZ18231Medicaid