Provider Demographics
NPI:1922480060
Name:MUNDO MANAGEMENT GROUP, LLC
Entity Type:Organization
Organization Name:MUNDO MANAGEMENT GROUP, LLC
Other - Org Name:MUNDO MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:DR. BLAKE KINGSBURY, D.M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:CARSON
Authorized Official - Last Name:KINGSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-825-2081
Mailing Address - Street 1:3463 HIGHWAY 21 BYP STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7245
Mailing Address - Country:US
Mailing Address - Phone:704-825-2081
Mailing Address - Fax:803-335-5189
Practice Address - Street 1:3463 HIGHWAY 21 BYP STE 1
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7245
Practice Address - Country:US
Practice Address - Phone:704-825-2081
Practice Address - Fax:803-335-5189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831338276Medicaid