Provider Demographics
NPI:1376053710
Name:LITTLE P.C.
Entity Type:Organization
Organization Name:LITTLE P.C.
Other - Org Name:EAST LAKE DENTAL HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-990-9998
Mailing Address - Street 1:4921 CENTRE POINTE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-6997
Mailing Address - Country:US
Mailing Address - Phone:843-990-9998
Mailing Address - Fax:864-670-5285
Practice Address - Street 1:2100 ROSWELL RD STE 1108
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-0883
Practice Address - Country:US
Practice Address - Phone:678-401-5089
Practice Address - Fax:864-670-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental