Healthcare Provider Details

I. General information

NPI: 1053376491
Provider Name (Legal Business Name): KIDS TEETH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 PROFESSIONAL LN
MOUNT PLEASANT SC
29466-7193
US

IV. Provider business mailing address

1130 PROFESSIONAL LN
MT PLEASANT SC
29466-7193
US

V. Phone/Fax

Practice location:
  • Phone: 843-216-5879
  • Fax: 843-310-3771
Mailing address:
  • Phone: 843-216-5879
  • Fax: 843-216-5891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3030
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number7171
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3881
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3863
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2085
License Number StateSC

VIII. Authorized Official

Name: REBECCA TORLAY - KURSH
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 843-216-5879