# LAKE WYLIE PEDIATRIC DENTISTRY, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ryan p colosi dds
- **Organization subpart:** No

## Provider details

- **NPI number:** 1528428091
- **Authorized official:** RYAN PETER COLOSI DDS (MEMBER)
- **Authorized official phone:** (803) 619-5155

## Contact information

- **Practice address:** 534 NAUTICAL DR., CLOVER, SC 29710-6102
- **Practice address phone:** (803) 619-5155
- **Mailing address:** 534 NAUTICAL DR, LAKE WYLIE, SC 29710-5001
- **Mailing address phone:** (803) 619-5155
- **Mailing address fax:** (803) 619-6575

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | 8097 | SC | Yes |

## Other

- **Enumeration date:** 02/26/2016
- **Last updated:** 03/24/2017