Provider Demographics
NPI:1851345557
Name:CHARLES B. MAXWELL, DMD, PA
Entity Type:Organization
Organization Name:CHARLES B. MAXWELL, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-386-2833
Mailing Address - Street 1:144 EAST BROADWAY ST.
Mailing Address - Street 2:PO BOX 297
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-0297
Mailing Address - Country:US
Mailing Address - Phone:843-386-2833
Mailing Address - Fax:843-386-2279
Practice Address - Street 1:144 EAST BROADWAY ST.
Practice Address - Street 2:
Practice Address - City:JOHNSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29555-0297
Practice Address - Country:US
Practice Address - Phone:843-386-2833
Practice Address - Fax:843-386-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2117261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ2117-4Medicaid