Provider Demographics
NPI:1225194558
Name:WACCAMAW PEDIATRIC DENTAL CARE, LLC
Entity type:Organization
Organization Name:WACCAMAW PEDIATRIC DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:SAMS
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-347-5654
Mailing Address - Street 1:158 WACCAMAW MEDICAL PARK CT
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8965
Mailing Address - Country:US
Mailing Address - Phone:843-347-5654
Mailing Address - Fax:843-347-3013
Practice Address - Street 1:158 WACCAMAW MEDICAL PARK CT
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8965
Practice Address - Country:US
Practice Address - Phone:843-347-5654
Practice Address - Fax:843-347-3013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9510Medicaid