Provider Demographics
NPI:1962847814
Name:COASTAL KIDS DENTAL PA
Entity Type:Organization
Organization Name:COASTAL KIDS DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIGGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-818-5437
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:843-818-5437
Mailing Address - Fax:
Practice Address - Street 1:8600 DORCHESTER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7382
Practice Address - Country:US
Practice Address - Phone:843-818-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38891223P0221X
SC44761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty