Provider Demographics
NPI: | 1851918882 |
---|---|
Name: | E.L. CENTRE POINTE PROFESSIONAL LLC |
Entity Type: | Organization |
Organization Name: | E.L. CENTRE POINTE PROFESSIONAL LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PERIODONTIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | LUKE |
Authorized Official - Middle Name: | ALEXANDER |
Authorized Official - Last Name: | LISZKA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 843-277-0102 |
Mailing Address - Street 1: | 4965 CENTRE POINTE DR STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | NORTH CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29418-6945 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-277-0102 |
Mailing Address - Fax: | 843-277-0422 |
Practice Address - Street 1: | 4965 CENTRE POINTE DR STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | NORTH CHARLESTON |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29418-6945 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-277-0102 |
Practice Address - Fax: | 843-277-0422 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-06-25 |
Last Update Date: | 2020-06-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0300X | Dental Providers | Dentist | Periodontics | Group - Multi-Specialty |