Provider Demographics
NPI:1578084331
Name:SEASIDE PEDIATRIC DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:SEASIDE PEDIATRIC DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-651-5437
Mailing Address - Street 1:4410 HIGHWAY 17 UNIT B6
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-6434
Mailing Address - Country:US
Mailing Address - Phone:423-741-9078
Mailing Address - Fax:
Practice Address - Street 1:4410 HIGHWAY 17 UNIT B6
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576
Practice Address - Country:US
Practice Address - Phone:423-741-9078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty