Basic Information
| Provider Information | |||||||||
| NPI: | 1174839674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | B. RYAN FLEMING, DDS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 LOCKWOOD DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437228500 | ||||||||
| FaxNumber: | 8437208555 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 LOCKWOOD DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437228500 | ||||||||
| FaxNumber: | 8437208555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | CARLOW | ||||||||
| AuthorizedOfficialFirstName: | JANELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUS MGR | ||||||||
| AuthorizedOfficialTelephone: | 8437228500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1313 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 4689 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | ZX-4689 | 05 | SC | MEDICAID | Z-1313 | 05 | SC | MEDICAID |