Healthcare Provider Details

I. General information

NPI: 1144002791
Provider Name (Legal Business Name): TEETH DS ISLE OF PALMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 21ST AVE
ISLE OF PALMS SC
29451-2384
US

IV. Provider business mailing address

15 21ST AVE
ISLE OF PALMS SC
29451-2384
US

V. Phone/Fax

Practice location:
  • Phone: 843-886-6461
  • Fax:
Mailing address:
  • Phone: 843-886-6461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: LUKE LISZKA
Title or Position: PERIODONTIST
Credential: DMD
Phone: 843-886-6461