Provider Demographics
NPI:1568678407
Name:AZALEA DENTAL LLC
Entity Type:Organization
Organization Name:AZALEA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-261-9754
Mailing Address - Street 1:310 N GUM ST STE B
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6874
Mailing Address - Country:US
Mailing Address - Phone:843-216-9754
Mailing Address - Fax:843-216-9756
Practice Address - Street 1:310 N GUM ST STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6874
Practice Address - Country:US
Practice Address - Phone:843-216-9754
Practice Address - Fax:843-216-9756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX03580Medicaid