Provider Demographics
NPI:1306912753
Name:JOSEPH, JOHN ANTHONY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:JOSEPH
Suffix:JR
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 1:107 HIGHMARKET ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3787
Mailing Address - Country:US
Mailing Address - Phone:843-546-5994
Mailing Address - Fax:843-546-4084
Practice Address - Street 1:632 FRONT ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3624
Practice Address - Country:US
Practice Address - Phone:843-546-5994
Practice Address - Fax:843-546-4084
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC933768Medicaid