1724 State Summerville Professional, LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

1724 STATE SUMMERVILLE PROFESSIONAL, LLC

Practice address

1724 State Rd Unit 4D
Summerville, SC 29486-2842

Phone

(843) 352-4454

Fax

(843) 352-4875

NPI assigned

Dec 7, 2021

Organization subpart

No

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

Authorized official

Name

Peter Grumbos, DDS

Title

Owner

Phone

(843) 352-4454

Specialties & licenses 1

Addresses

Other names 1

• Cane Bay Family Dentistry Doing business as

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

{
    "created_epoch": "1638835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1638835200000",
    "number": "1730847724",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1724 STATE RD UNIT 4D",
            "city": "SUMMERVILLE",
            "state": "SC",
            "postal_code": "294862842",
            "telephone_number": "843-352-4454",
            "fax_number": "843-352-4875"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1724 STATE RD UNIT 4D",
            "city": "SUMMERVILLE",
            "state": "SC",
            "postal_code": "294862842",
            "telephone_number": "843-352-4454",
            "fax_number": "843-352-4875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1724 STATE SUMMERVILLE PROFESSIONAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-12-07",
        "last_updated": "2021-12-07",
        "certification_date": "2021-11-29",
        "status": "A",
        "authorized_official_last_name": "GRUMBOS",
        "authorized_official_first_name": "PETER",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "843-352-4454",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cane Bay Family Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• All providers in Summerville, SC
• General Practice Dentistry in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 7, 2021; 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.