Provider Demographics
NPI:1801036637
Name:COASTAL KIDS DENTAL
Entity Type:Organization
Organization Name:COASTAL KIDS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISABEL
Authorized Official - Middle Name:GHOWANLU
Authorized Official - Last Name:DRIGGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-478-8437
Mailing Address - Street 1:1000 TANNER FORD BLVD
Mailing Address - Street 2:SUITE 370
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-4707
Mailing Address - Country:US
Mailing Address - Phone:843-478-8437
Mailing Address - Fax:
Practice Address - Street 1:1931 STRATHMOOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2525
Practice Address - Country:US
Practice Address - Phone:843-478-8437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC38891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3889Medicaid