Provider Demographics
NPI:1902345630
Name:SMILE ON CHARLESTON, LLC
Entity Type:Organization
Organization Name:SMILE ON CHARLESTON, LLC
Other - Org Name:BLACKMAN & LINEBERGER ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-892-3300
Mailing Address - Street 1:91 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1722
Mailing Address - Country:US
Mailing Address - Phone:843-577-7477
Mailing Address - Fax:
Practice Address - Street 1:91 RUTLEDGE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1722
Practice Address - Country:US
Practice Address - Phone:843-577-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8066261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental