Provider Demographics
NPI:1336603554
Name:TERRIFIC TEETH PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:TERRIFIC TEETH PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-819-5276
Mailing Address - Street 1:1325 MILTON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15218-1234
Mailing Address - Country:US
Mailing Address - Phone:703-819-5276
Mailing Address - Fax:
Practice Address - Street 1:1229 SILVER LN
Practice Address - Street 2:
Practice Address - City:MC KEES ROCKS
Practice Address - State:PA
Practice Address - Zip Code:15136-1063
Practice Address - Country:US
Practice Address - Phone:412-859-3199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty