Healthcare Provider Details

I. General information

NPI: 1811968159
Provider Name (Legal Business Name): DS DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 BAYBORO ST.
LORIS SC
29569
US

IV. Provider business mailing address

PO BOX 369
LORIS SC
29569
US

V. Phone/Fax

Practice location:
  • Phone: 843-756-2273
  • Fax: 843-756-0242
Mailing address:
  • Phone: 843-756-2273
  • Fax: 843-756-0242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LACEY JANE SPIGUZZA
Title or Position: VICE PRESIDENT
Credential:
Phone: 765-220-0620