Provider Demographics
NPI:1730467978
Name:CHILDREN'S DENTAL CLINIC OF CHARLESTON, LLC
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL CLINIC OF CHARLESTON, LLC
Other - Org Name:CHILDREN'S WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANEAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0342
Mailing Address - Street 1:618 CHURCH ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-2428
Mailing Address - Country:US
Mailing Address - Phone:615-750-0342
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:6035 RIVERS AVE STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-5018
Practice Address - Country:US
Practice Address - Phone:843-572-9909
Practice Address - Fax:843-572-9901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S DENTAL CLINIC OF CHARLESTON, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid