Provider Demographics
NPI:1730415092
Name:WILD SMILES WHITE KNOLL FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:WILD SMILES WHITE KNOLL FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUNJIT
Authorized Official - Middle Name:RICK
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-356-1606
Mailing Address - Street 1:1767 S LAKE DR
Mailing Address - Street 2:SUITE # A
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-6734
Mailing Address - Country:US
Mailing Address - Phone:803-356-1606
Mailing Address - Fax:803-359-7542
Practice Address - Street 1:1767 S LAKE DR
Practice Address - Street 2:SUITE # A
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-6734
Practice Address - Country:US
Practice Address - Phone:803-356-1606
Practice Address - Fax:803-359-7542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC38641223G0001X
SCSC38011223P0221X
SCSC33511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty