Provider Demographics
NPI:1710442967
Name:CENTRAL CAROLINA ENDODONTICS PA
Entity Type:Organization
Organization Name:CENTRAL CAROLINA ENDODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DAVIN
Authorized Official - Last Name:BONAVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-516-0777
Mailing Address - Street 1:888 COOK ROAD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118
Mailing Address - Country:US
Mailing Address - Phone:803-516-0777
Mailing Address - Fax:803-516-0577
Practice Address - Street 1:888 COOK ROAD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118
Practice Address - Country:US
Practice Address - Phone:803-516-0777
Practice Address - Fax:803-516-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty