Provider Demographics
NPI:1275315822
Name:TEETH DS DANIEL ISLAND LLC
Entity Type:Organization
Organization Name:TEETH DS DANIEL ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISZKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-284-4444
Mailing Address - Street 1:240 SEVEN FARMS DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8988
Mailing Address - Country:US
Mailing Address - Phone:843-284-4444
Mailing Address - Fax:
Practice Address - Street 1:240 SEVEN FARMS DR STE 101
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-8988
Practice Address - Country:US
Practice Address - Phone:843-284-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEETH DS DANIEL ISLAND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty