Provider Demographics
NPI:1134837503
Name:LONGBOARD DENTAL LLC
Entity type:Organization
Organization Name:LONGBOARD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:PAULISICK
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAGD
Authorized Official - Phone:843-654-1373
Mailing Address - Street 1:405 FAISON ROAD
Mailing Address - Street 2:SUIRE A3
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466
Mailing Address - Country:US
Mailing Address - Phone:843-654-1373
Mailing Address - Fax:843-654-1374
Practice Address - Street 1:405 FAISON ROAD
Practice Address - Street 2:SUIRE A3
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466
Practice Address - Country:US
Practice Address - Phone:843-654-1373
Practice Address - Fax:843-654-1374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental