Provider Demographics
NPI:1386030351
Name:VICTORY DENTISTRY FOR KIDS
Entity Type:Organization
Organization Name:VICTORY DENTISTRY FOR KIDS
Other - Org Name:VICTORY PEDIATRIC DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TASHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-228-0525
Mailing Address - Street 1:9787 CHARLOTTE HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5511
Mailing Address - Country:US
Mailing Address - Phone:803-547-2280
Mailing Address - Fax:
Practice Address - Street 1:9787 CHARLOTTE HWY STE 203
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-5511
Practice Address - Country:US
Practice Address - Phone:803-547-2280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4382305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service