Healthcare Provider Details

I. General information

NPI: 1104678028
Provider Name (Legal Business Name): TEETH SPECIALTY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 JOHNNIE DODDS BLVD STE 120
MT PLEASANT SC
29464-5909
US

IV. Provider business mailing address

1010 OCEAN BLVD UNIT 203
ISLE OF PALMS SC
29451-1701
US

V. Phone/Fax

Practice location:
  • Phone: 403-909-0302
  • Fax:
Mailing address:
  • Phone: 403-909-0302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LUKE LISZKA
Title or Position: PERIODONTIST
Credential: DMD
Phone: 403-909-0302