Provider Demographics
NPI:1376932798
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 1:118 S WALTER ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-3956
Practice Address - Country:US
Practice Address - Phone:843-818-5437
Practice Address - Fax:843-725-1594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL KIDS DENTAL, PA
Parent Organization TIN:<UNAVAIL>
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