Provider Demographics
NPI:1881800480
Name:GRAND STRAND PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:GRAND STRAND PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WINONA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-294-5437
Mailing Address - Street 1:3112 DICK POND ROAD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-4833
Mailing Address - Country:US
Mailing Address - Phone:843-294-5437
Mailing Address - Fax:843-294-5440
Practice Address - Street 1:3112 DICK POND ROAD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4833
Practice Address - Country:US
Practice Address - Phone:843-294-5437
Practice Address - Fax:843-294-5440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND STRAND PEDIATRIC DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-14
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31251223P0221X
SC3125SC1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9590Medicaid