Provider Demographics
NPI:1154019636
Name:SEVERANCE, LUKE ELLINGTON (DMD)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:ELLINGTON
Last Name:SEVERANCE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 FOLLY ROAD BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7547
Mailing Address - Country:US
Mailing Address - Phone:843-610-0815
Mailing Address - Fax:
Practice Address - Street 1:538 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7210
Practice Address - Country:US
Practice Address - Phone:843-722-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC102561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice