Provider Demographics
NPI:1851906028
Name:CAROLINA PARK FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:CAROLINA PARK FAMILY DENTISTRY LLC
Other - Org Name:CAROLINA PARK FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLEBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-654-1918
Mailing Address - Street 1:3520 PARK AVENUE BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7567
Mailing Address - Country:US
Mailing Address - Phone:843-654-1918
Mailing Address - Fax:
Practice Address - Street 1:3520 PARK AVENUE BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-2946
Practice Address - Country:US
Practice Address - Phone:843-654-1918
Practice Address - Fax:843-654-1917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty