Provider Demographics
NPI:1720552524
Name:SFD KNIGHTSVILLE LLC
Entity Type:Organization
Organization Name:SFD KNIGHTSVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZZLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-871-0842
Mailing Address - Street 1:1971 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7890
Mailing Address - Country:US
Mailing Address - Phone:843-871-0842
Mailing Address - Fax:
Practice Address - Street 1:487 W BUTTERNUT RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5568
Practice Address - Country:US
Practice Address - Phone:843-871-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A. FREDERICK SOLOMON DMD P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8553Medicaid