Provider Demographics
NPI:1225410558
Name:HAPPY TEETH HAPPY KIDS, LLC
Entity Type:Organization
Organization Name:HAPPY TEETH HAPPY KIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-839-4554
Mailing Address - Street 1:3074 DEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1569
Mailing Address - Country:US
Mailing Address - Phone:843-839-4554
Mailing Address - Fax:843-839-4043
Practice Address - Street 1:3074 DEVILLE ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1569
Practice Address - Country:US
Practice Address - Phone:843-839-4554
Practice Address - Fax:843-839-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44061223G0001X
SC44291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1144462698Medicaid
SC1336337047Medicaid