Provider Demographics
NPI:1740396084
Name:CHARLES E MILLWOOD JR DMD, PA
Entity Type:Organization
Organization Name:CHARLES E MILLWOOD JR DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MILLWOOD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-796-1734
Mailing Address - Street 1:1313 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033
Mailing Address - Country:US
Mailing Address - Phone:803-796-1734
Mailing Address - Fax:803-796-5041
Practice Address - Street 1:1313 STATE STREET
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033
Practice Address - Country:US
Practice Address - Phone:803-796-1734
Practice Address - Fax:803-796-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ18570Medicaid
SCZA9850Medicaid