Provider Demographics
NPI:1841667037
Name:MIDLANDS PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:MIDLANDS PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAFORREST
Authorized Official - Last Name:SHOUN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-348-8976
Mailing Address - Street 1:221 SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2474
Mailing Address - Country:US
Mailing Address - Phone:803-951-7337
Mailing Address - Fax:
Practice Address - Street 1:253 CEDARCREST DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3812
Practice Address - Country:US
Practice Address - Phone:803-951-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty