Healthcare Provider Details

I. General information

NPI: 1386244846
Provider Name (Legal Business Name): TEETH DS ISLE OF PALMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 347
ISLE OF PALMS SC
29451-0347
US

V. Phone/Fax

Practice location:
  • Phone: 843-886-6461
  • Fax: 843-886-3957
Mailing address:
  • Phone: 843-886-6461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LUKE LISZKA
Title or Position: OWNER
Credential: DMD
Phone: 843-886-6461