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General NPI Number Information
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NPI Number | 1023993912
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Entity Type | Organization
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Legal Business Name | SOUTHERN TIDES DENTAL
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Dates
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Enumeration Date | 08/08/2025
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Last Update Date | 08/08/2025
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Provider Practice Location Address
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Address Line | 1701 BEAUCASTLE RD STE B
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City | MT PLEASANT
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State | SC
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Zip | 29464-3685
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Country | US
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Telephone | 843-258-8604
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Fax |
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Provider Business Mailing Address
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Address Line | 1850 CREST RD
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City | MARYVILLE
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State | TN
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Zip | 37804-4305
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Country | US
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Telephone | 865-982-1700
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Fax |
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Authorized Official
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Title or Position | COACH
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Name | HOLLIE A FOUST
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Credential | DA
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Telephone | 803-322-6020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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