Healthcare Provider Details

I. General information

NPI: 1578084331
Provider Name (Legal Business Name): SEASIDE PEDIATRIC DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 HIGHWAY 17 UNIT B6
MURRELLS INLET SC
29576
US

IV. Provider business mailing address

4410 HIGHWAY 17 UNIT B6
MURRELLS INLET SC
29576-6434
US

V. Phone/Fax

Practice location:
  • Phone: 423-741-9078
  • Fax:
Mailing address:
  • Phone: 423-741-9078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MATTHEW TILLMAN
Title or Position: CO-OWNER
Credential: DDS
Phone: 843-651-5437