Provider Demographics
NPI:1881471134
Name:LE SUMMERVILLE DENTAL LLC
Entity type:Organization
Organization Name:LE SUMMERVILLE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:LISZKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-875-5111
Mailing Address - Street 1:101 HARTH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8107
Mailing Address - Country:US
Mailing Address - Phone:843-875-5111
Mailing Address - Fax:
Practice Address - Street 1:240 SEVEN FARMS DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492
Practice Address - Country:US
Practice Address - Phone:843-284-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:L E SUMMERVILLE DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty