MEDICARE: COASTAL KIDS DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223G0001X	General Practice Dentistry
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
3	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1093117558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL KIDS DENTAL

Provider Business Mailing Address
First Line	:	808 WAPPOO RD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-5865
Country	:	US
Telephone Number	:	843-818-5437
Fax Number	:	843-725-1594

Provider Business Practice Location Address
First Line	:	808 WAPPOO RD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-5865
Country	:	US
Telephone Number	:	843-818-5437
Fax Number	:	843-725-1594

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JACOB DRIGGERS
Credential	:
Telephone Number	:	843-818-5437

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	09/16/2014

Similar Medicare Providers

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Practice Location Address:

808 WAPPOO RD
CHARLESTON, SC
29407-5865

Practice Phone: 843-818-5437
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1336380054 — MS. KERRI R PAKURAR BCBA
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1043634637 — MRS. ASHLEY BROOKE UNDERWOOD ULBRICHT BCBA
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1841689247 — COASTAL KIDS DENTAL & BRACES
Practice Location Address:

808 WAPPOO RD
CHARLESTON, SC
29407-5865

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1700262540 — KATHERINE ADELMAN BCABA
Practice Location Address:

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1285090423 — JEFFREY MIRRIELEES
Practice Location Address:

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29407-5865

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