Provider Demographics
NPI:1801142567
Name:JENNIFER BERWICK PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JENNIFER BERWICK PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BALLANTYNE
Authorized Official - Last Name:BERWICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-571-5533
Mailing Address - Street 1:376 SUMTER ST APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-4902
Mailing Address - Country:US
Mailing Address - Phone:843-571-5533
Mailing Address - Fax:843-571-5534
Practice Address - Street 1:712 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7141
Practice Address - Country:US
Practice Address - Phone:843-571-5533
Practice Address - Fax:843-571-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4396261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental