Provider Demographics
NPI:1770006876
Name:SOLOMON KIDS PEDIATRIC DENTISTRY KNIGHTSVILLE LLC
Entity Type:Organization
Organization Name:SOLOMON KIDS PEDIATRIC DENTISTRY KNIGHTSVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAZZLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-871-0842
Mailing Address - Street 1:1971 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7820
Mailing Address - Country:US
Mailing Address - Phone:843-871-0842
Mailing Address - Fax:
Practice Address - Street 1:491 W BUTTERNUT RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5507
Practice Address - Country:US
Practice Address - Phone:843-871-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85261223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8526Medicaid
SCZX8227Medicaid