Healthcare Provider Details

I. General information

NPI: 1336917145
Provider Name (Legal Business Name): LITTLE WAVES PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 05/30/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 OLEANDER DRIVE UNIT 3,4,5
MYRTLE BEACH SC
29577
US

IV. Provider business mailing address

584 STARLIT WAY
MYRTLE BEACH SC
29579-4322
US

V. Phone/Fax

Practice location:
  • Phone: 843-353-3319
  • Fax: 843-353-3238
Mailing address:
  • Phone:
  • 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: LORI PORRAS
Title or Position: PEDIATRIC DENTIST
Credential: DMD
Phone: 954-383-3893