| NPI | 1801895115 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLY W FORD Owner 843-871-6636 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: SC 1790) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: SC 3045) |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2020-08-22 |