Provider Demographics
NPI:1528428091
Name:LAKE WYLIE PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:LAKE WYLIE PEDIATRIC DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:COLOSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:803-619-5155
Mailing Address - Street 1:534 NAUTICAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-5001
Mailing Address - Country:US
Mailing Address - Phone:803-619-5155
Mailing Address - Fax:803-619-6575
Practice Address - Street 1:534 NAUTICAL DR.
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-6102
Practice Address - Country:US
Practice Address - Phone:803-619-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC80971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty