Healthcare Provider Details

I. General information

NPI: 1841689247
Provider Name (Legal Business Name): COASTAL KIDS DENTAL & BRACES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 WAPPOO RD
CHARLESTON SC
29407-5865
US

IV. Provider business mailing address

808 WAPPOO RD
CHARLESTON SC
29407-5865
US

V. Phone/Fax

Practice location:
  • Phone: 843-818-5437
  • Fax: 843-725-1594
Mailing address:
  • Phone: 843-818-5437
  • Fax: 843-725-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4209
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4476
License Number StateSC

VIII. Authorized Official

Name: JACOB DRIGGERS
Title or Position: COO
Credential:
Phone: 843-818-5437