Provider Demographics
NPI:1942619671
Name:SMILEOLOGY DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:SMILEOLOGY DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-767-8555
Mailing Address - Street 1:6518 DORCHESTER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-5100
Mailing Address - Country:US
Mailing Address - Phone:843-767-8555
Mailing Address - Fax:843-793-3344
Practice Address - Street 1:6518 DORCHESTER RD
Practice Address - Street 2:SUITE A
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-5100
Practice Address - Country:US
Practice Address - Phone:843-767-8555
Practice Address - Fax:843-793-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1396940458Medicaid