Healthcare Provider Details

I. General information

NPI: 1174082713
Provider Name (Legal Business Name): INDIGO PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 POWDERSVILLE RD STE A
EASLEY SC
29642-2417
US

IV. Provider business mailing address

1026 POWDERSVILLE RD STE A
EASLEY SC
29642-2417
US

V. Phone/Fax

Practice location:
  • Phone: 864-442-6770
  • Fax: 864-442-6830
Mailing address:
  • Phone: 864-442-6770
  • Fax: 864-442-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierZA8955
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
Identifier1609282425
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerNPI
# 3
IdentifierZX8355
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: DR. RULA MAHMOUD SHALABI
Title or Position: OWNER, PEDIATRIC DENTIST
Credential: DMD
Phone: 864-442-6770