Lake Moultrie Dental LLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

LAKE MOULTRIE DENTAL LLC

Practice address

205 Carolina Ave
Moncks Corner, SC 29461-3736

Phone

(843) 761-8720

NPI assigned

Oct 10, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Brian Lewis Jaques, DMD

Title

Owner/Dentist

Phone

(843) 761-8720

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Tong Yang, DMD

  • General Practice Dentistry
  • Gulfport, MS
  • NPI 1427655901
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1539129600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1539129600000",
    "number": "1013482603",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 CAROLINA AVE",
            "city": "MONCKS CORNER",
            "state": "SC",
            "postal_code": "294613736",
            "telephone_number": "843-761-8720"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 CAROLINA AVE",
            "city": "MONCKS CORNER",
            "state": "SC",
            "postal_code": "294613736",
            "telephone_number": "843-761-8720"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE MOULTRIE DENTAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-10-10",
        "last_updated": "2018-10-10",
        "status": "A",
        "authorized_official_last_name": "JAQUES",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "LEWIS",
        "authorized_official_title_or_position": "OWNER/DENTIST",
        "authorized_official_telephone_number": "843-761-8720",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZX8370",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Heather Nicole Kizer, COTA/L
• Robyn Komar, LPN
• Allison M. Krakeel, APRN
• Terry Lynn Kunkle II, DMD
• Terry Lynn Kunkle Sr., DMD
• Lakeside Family Center
• Ronice M Lampkin, RN
• Kathleen Marie Lance, APN
• Patricia A Landreman, RN
• Lucy N. Lapoint, PA-C

• Dental Clinic/Center in Moncks Corner, SC
• Providers in Moncks Corner, SC by specialty
• Dental Clinic/Center in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.