Provider Demographics
NPI:1750958666
Name:CAROLINA ROOTS DENTISTRY LLC
Entity type:Organization
Organization Name:CAROLINA ROOTS DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-631-6644
Mailing Address - Street 1:2038 COUNTRY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9905 CALVIN HALL ROAD
Practice Address - Street 2:100
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707
Practice Address - Country:US
Practice Address - Phone:864-631-6644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental