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General NPI Number Information
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NPI Number | 1598400475
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Entity Type | Organization
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Legal Business Name | RIVERSIDE PEDIATRIC DENTISTRY LLC
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Dates
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Enumeration Date | 05/04/2022
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Last Update Date | 05/04/2022
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Provider Practice Location Address
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Address Line | 461 W CHEVES ST
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City | FLORENCE
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State | SC
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Zip | 29501-4446
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Country | US
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Telephone | 843-601-2442
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5776
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City | FLORENCE
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State | SC
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Zip | 29502-5776
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Country | US
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Telephone | 843-601-2442
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KATHY BOURGOYNE
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Credential |
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Telephone | 843-536-9888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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