Provider Demographics
NPI:1043301146
Name:LOWCOUNTRY CENTER FOR PROSTHODONTIC CARE
Entity type:Organization
Organization Name:LOWCOUNTRY CENTER FOR PROSTHODONTIC CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:
Authorized Official - Last Name:VACAREAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-706-3800
Mailing Address - Street 1:25 CLARK SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-4205
Mailing Address - Country:US
Mailing Address - Phone:843-706-3800
Mailing Address - Fax:843-706-3802
Practice Address - Street 1:25 CLARK SUMMIT DR
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-4205
Practice Address - Country:US
Practice Address - Phone:843-706-3800
Practice Address - Fax:843-706-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3764122300000X
SC05851223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3764Medicaid