Healthcare Provider Details

I. General information

NPI: 1841901824
Provider Name (Legal Business Name): TIFFANY SAMANTHA COAXUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 NASSAU ST
CHARLESTON SC
29403-5513
US

IV. Provider business mailing address

118 HAINSWORTH DR
NORTH CHARLESTON SC
29418-2736
US

V. Phone/Fax

Practice location:
  • Phone: 843-722-4112
  • Fax:
Mailing address:
  • Phone: 843-492-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11083
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: