Provider Demographics
NPI:1386244846
Name:TEETH DS ISLE OF PALMS
Entity type:Organization
Organization Name:TEETH DS ISLE OF PALMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISZKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-886-6461
Mailing Address - Street 1:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-0347
Mailing Address - Country:US
Mailing Address - Phone:843-886-6461
Mailing Address - Fax:
Practice Address - Street 1:15 21ST AVE
Practice Address - Street 2:
Practice Address - City:ISLE OF PALMS
Practice Address - State:SC
Practice Address - Zip Code:29451-2384
Practice Address - Country:US
Practice Address - Phone:843-886-6461
Practice Address - Fax:843-886-3957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9325OtherDENTAL