Provider Demographics
NPI:1104363233
Name:KINGSTREE FAMILY DENTISRY LLC
Entity Type:Organization
Organization Name:KINGSTREE FAMILY DENTISRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-819-1524
Mailing Address - Street 1:325 FOLLY RD
Mailing Address - Street 2:STE 310
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2507
Mailing Address - Country:US
Mailing Address - Phone:843-737-4437
Mailing Address - Fax:
Practice Address - Street 1:1200 N LONGSTREET ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-2738
Practice Address - Country:US
Practice Address - Phone:843-355-5554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6968261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental