Provider Demographics
NPI:1124238407
Name:CAROLINA CENTER FOR COSMETIC AND RESTORATIVE DENTISTRY, LLC
Entity type:Organization
Organization Name:CAROLINA CENTER FOR COSMETIC AND RESTORATIVE DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HOROWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-248-3843
Mailing Address - Street 1:1515 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4107
Mailing Address - Country:US
Mailing Address - Phone:843-248-3843
Mailing Address - Fax:843-248-8802
Practice Address - Street 1:1515 9TH AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4107
Practice Address - Country:US
Practice Address - Phone:843-248-3843
Practice Address - Fax:843-248-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty