Provider Demographics
NPI:1194144493
Name:CHARLESTON FACIAL PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:CHARLESTON FACIAL PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WASTSON
Authorized Official - Last Name:RODWELL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:843-882-7181
Mailing Address - Street 1:281 E SHORE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 BROAD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-2936
Practice Address - Country:US
Practice Address - Phone:843-882-7181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL36529207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty