Provider Demographics
NPI:1770918351
Name:PEDO CAROLINA, INC.
Entity type:Organization
Organization Name:PEDO CAROLINA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD, MSD
Authorized Official - Phone:704-763-4931
Mailing Address - Street 1:2460 INDIA HOOK RD STE 106
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3530
Mailing Address - Country:US
Mailing Address - Phone:704-763-4931
Mailing Address - Fax:
Practice Address - Street 1:2460 INDIA HOOK RD STE 106
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3530
Practice Address - Country:US
Practice Address - Phone:704-763-4931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4509-7981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty