Organization
LAKE MOULTRIE DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRIAN LEWIS JAQUES DMD (OWNER/DENTIST)
(843) 761-8720
Entity
Organization
Contact information
Practice address
205 CAROLINA AVE, MONCKS CORNER, SC 29461-3736
(843) 761-8720
Mailing address
205 CAROLINA AVE, MONCKS CORNER, SC 29461-3736
(843) 761-8720
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ZX8370
—
SC
Enumeration date
10/10/2018
Last updated
10/10/2018
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