Provider Demographics
NPI:1043373327
Name:HORRES, JOHN JACOB IV (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JACOB
Last Name:HORRES
Suffix:IV
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 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:843-722-3199
Mailing Address - Fax:
Practice Address - Street 1:101 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:843-722-3199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC279623Medicaid