Provider Demographics
NPI:1629749106
Name:CAROLINA FAMILY DENTISTRY AT LAKE WYLIE
Entity Type:Organization
Organization Name:CAROLINA FAMILY DENTISTRY AT LAKE WYLIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:N
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-831-2171
Mailing Address - Street 1:244 LATITUDE LN STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8125
Mailing Address - Country:US
Mailing Address - Phone:803-831-2171
Mailing Address - Fax:
Practice Address - Street 1:244 LATITUDE LN STE 103
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-8125
Practice Address - Country:US
Practice Address - Phone:803-831-2171
Practice Address - Fax:803-831-2172
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA FAMILY DENTISTRY AT LAKE WYLIE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1639539653OtherDENTIST
SC1528635604OtherDENTIST
SC1083818157OtherDENTIST