Healthcare Provider Details

I. General information

NPI: 1174112387
Provider Name (Legal Business Name): TEGA CAY FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 STONECREST BLVD
TEGA CAY SC
29708-6632
US

IV. Provider business mailing address

1188 STONECREST BLVD
TEGA CAY SC
29708-6632
US

V. Phone/Fax

Practice location:
  • Phone: 888-764-5314
  • Fax:
Mailing address:
  • Phone: 888-764-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JULIA CORREAL
Title or Position: OWENER
Credential: DDS
Phone: 888-764-5314