Organization
RIVERSIDE PEDIATRIC DENTISTRY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KATHY BOURGOYNE (OFFICE MANAGER)
(843) 536-9888
Entity
Organization
Contact information
Practice address
461 W CHEVES ST, FLORENCE, SC 29501-4446
(843) 601-2442
Mailing address
PO BOX 5776, FLORENCE, SC 29502-5776
(843) 601-2442
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ZX8488
—
SC
Enumeration date
05/04/2022
Last updated
05/04/2022
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