Johan I Kolmodin, DMD
Individual provider Active NPI Dentist · Hanahan, SC
NPI 1497721955 · NPPES record last updated Feb 3, 2009
Key facts
- NPI
- 1497721955
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 3436 (SC)
- Practice address
- 1005 Tanner Ford Blvd
Suite 102
Hanahan, SC 29410 - Phone
- (843) 797-6287
- Fax
- (843) 797-6292
- NPI assigned
- Feb 24, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in SC
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20140428000213 | SC | Order and Referring Only - Oral Surgery |
2264665231 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 3436 | SC | Yes |
Addresses
Primary practice location
1005 Tanner Ford Blvd
Suite 102
Hanahan, SC 29410
Mailing address
1005 Tanner Ford Blvd
Suite 102
Hanahan, SC 29410
Phone (843) 797-6287
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 963368 | Other | GA | BLUE CROSS |
| Z34368 | Medicaid | SC | |
| 817149 | Other | UNITED CONCORDIA |
Other providers in Hanahan, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 3, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.