Provider Demographics
NPI:1144002791
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:PERIODONTIST
Authorized Official - Prefix:
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 1:15 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2384
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEETH DS ISLE OF PALMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty