Provider Demographics
NPI:1124417522
Name:COASTAL KIDS DENTAL & BRACES
Entity Type:Organization
Organization Name:COASTAL KIDS DENTAL & BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIGGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-818-5437
Mailing Address - Street 1:808 WAPPOO RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5865
Mailing Address - Country:US
Mailing Address - Phone:843-818-5437
Mailing Address - Fax:843-725-1594
Practice Address - Street 1:8600 DORCHESTER RD
Practice Address - Street 2:STE 104
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7382
Practice Address - Country:US
Practice Address - Phone:843-818-5437
Practice Address - Fax:843-725-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44761223X0400X
SC42091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty