Provider Demographics
NPI:1427499540
Name:SAWGRASS PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:SAWGRASS PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-236-7500
Mailing Address - Street 1:210 VILLAGE CENTER BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6706
Mailing Address - Country:US
Mailing Address - Phone:843-236-7500
Mailing Address - Fax:843-236-7550
Practice Address - Street 1:210 VILLAGE CENTER BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6706
Practice Address - Country:US
Practice Address - Phone:843-236-7500
Practice Address - Fax:843-236-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC791 PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty