Healthcare Provider Details

I. General information

NPI: 1225410558
Provider Name (Legal Business Name): HAPPY TEETH HAPPY KIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3074 DEVILLE ST
MYRTLE BEACH SC
29577-1569
US

IV. Provider business mailing address

3074 DEVILLE ST
MYRTLE BEACH SC
29577-1569
US

V. Phone/Fax

Practice location:
  • Phone: 843-839-4554
  • Fax: 843-839-4043
Mailing address:
  • Phone: 843-839-4554
  • Fax: 843-839-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number4429
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4406
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier1144462698
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
Identifier1336337047
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MS. MARLENE MENDEZ
Title or Position: OWNER
Credential: DMD
Phone: 843-839-4554