Provider Demographics
NPI:1447040431
Name:FORTH DENTAL CHARLESTON, LLC
Entity type:Organization
Organization Name:FORTH DENTAL CHARLESTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PHIMVONGSA
Authorized Official - Suffix:
Authorized Official - Credentials:OPERATIONAL MANAGER
Authorized Official - Phone:702-354-4569
Mailing Address - Street 1:454 CLEMSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7925
Mailing Address - Country:US
Mailing Address - Phone:034-623-6628
Mailing Address - Fax:803-619-6053
Practice Address - Street 1:454 CLEMSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7925
Practice Address - Country:US
Practice Address - Phone:034-623-6628
Practice Address - Fax:803-619-6053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty