Provider Demographics
NPI:1013482603
Name:LAKE MOULTRIE DENTAL LLC
Entity Type:Organization
Organization Name:LAKE MOULTRIE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:JAQUES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-761-8720
Mailing Address - Street 1:205 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3736
Mailing Address - Country:US
Mailing Address - Phone:843-761-8720
Mailing Address - Fax:
Practice Address - Street 1:205 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3736
Practice Address - Country:US
Practice Address - Phone:843-761-8720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8370Medicaid