Healthcare Provider Details

I. General information

NPI: 1235203886
Provider Name (Legal Business Name): KOOL SMILES P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3227 W BLUE RIDGE DR
GREENVILLE SC
29611-3905
US

IV. Provider business mailing address

PO BOX 67
TAYLORS SC
29687-0002
US

V. Phone/Fax

Practice location:
  • Phone: 510-290-4744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4543
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4543
License Number StateSC

VIII. Authorized Official

Name: DR. ANGELA C BLACK
Title or Position: DENTIST
Credential: DMD
Phone: 510-290-4744