Provider Demographics
NPI:1417464371
Name:ADULT AND CHILDRENS DENTISTRY AT MYRTLE BEACH LLC
Entity Type:Organization
Organization Name:ADULT AND CHILDRENS DENTISTRY AT MYRTLE BEACH LLC
Other - Org Name:ADULT AND CHILDRENS DENTISTRY AT CAROLINA FOREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-903-8800
Mailing Address - Street 1:4032 RIVER OAKS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4032 RIVER OAKS DR STE 2
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6696
Practice Address - Country:US
Practice Address - Phone:843-903-8800
Practice Address - Fax:843-903-8575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-01
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34461223G0001X
SC88611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty