Healthcare Provider Details

I. General information

NPI: 1366580276
Provider Name (Legal Business Name): PAWLEYS ISLAND PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9462 OCEAN HIGHWAY
PAWLEYS ISLAND SC
29585
US

IV. Provider business mailing address

9462 OCEAN HWY PO BOX 3595
PAWLEYS ISLAND SC
29585
US

V. Phone/Fax

Practice location:
  • Phone: 843-235-0536
  • Fax: 843-237-8459
Mailing address:
  • Phone: 843-235-0536
  • Fax: 843-237-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3910
License Number StateSC

VII. Legacy identifiers

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

# 1
IdentifierZA9537
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: DR. MEREDITH LUCIUS PAPADEA
Title or Position: PRESIDENT
Credential: DMD
Phone: 843-235-0536