1053376491 NPI number — KIDS TEETH, LLC

Table of content: (NPI 1053376491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053376491 NPI number — KIDS TEETH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS TEETH, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WROBLESKI & MACDONALD PEDIATRIC DENTAL PARTNERSHIP
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053376491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 PROFESSIONAL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29466-7193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-216-5879
Provider Business Mailing Address Fax Number:
843-216-5891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
389 JOHNNIE DODDS BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-884-7041
Provider Business Practice Location Address Fax Number:
843-971-9299
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIERSCHEM
Authorized Official First Name:
BELINDA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
843-216-5879

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  2085 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: 3881 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 3863 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 3030 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 7171 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZX3881 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z20850 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZA9866 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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