Provider Demographics
NPI:1649725102
Name:CAROLINA PERIODONTICS & DENTAL IMPLANTS
Entity type:Organization
Organization Name:CAROLINA PERIODONTICS & DENTAL IMPLANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-289-0507
Mailing Address - Street 1:112 W BROAD ST UNIT 405
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 W BROAD ST UNIT 405
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2688
Practice Address - Country:US
Practice Address - Phone:480-289-0507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86381223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty