Provider Demographics
NPI:1982105904
Name:SWEET TOOTH SMILES P A
Entity Type:Organization
Organization Name:SWEET TOOTH SMILES P A
Other - Org Name:DENTAL SLEEP DOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:MARGUERITE
Authorized Official - Last Name:JOHANNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-254-9865
Mailing Address - Street 1:112 MALLARD LAKES CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9300
Mailing Address - Country:US
Mailing Address - Phone:920-254-9865
Mailing Address - Fax:
Practice Address - Street 1:3020 SUNSET BLVD STE 106
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3494
Practice Address - Country:US
Practice Address - Phone:803-233-1980
Practice Address - Fax:803-602-6397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-25
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4571122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty