Healthcare Provider Details

I. General information

NPI: 1851662274
Provider Name (Legal Business Name): ALEXIS COLLINS CHILDRENS DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 SAINT ANDREWS RD
COLUMBIA SC
29210-4427
US

IV. Provider business mailing address

1774 DUTCH FORK RD
IRMO SC
29063-8829
US

V. Phone/Fax

Practice location:
  • Phone: 803-772-7302
  • Fax: 803-772-7353
Mailing address:
  • Phone: 803-772-7302
  • Fax: 803-772-7353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4507
License Number StateSC

VIII. Authorized Official

Name: ALEXIS COLLINS
Title or Position: OWNER
Credential:
Phone: 803-772-7302