| Organization Name: | LAKE WYLIE PEDIATRIC DENTISTRY, LLC |
| NPI Number: | 1528428091 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RYAN PETER COLOSI (MEMBER) |
| Mailing Address: | 439 Channel Rd Lake Wylie |
| State: | SC US |
| Postal Code: | 297106102 |
| Phone Number: | 7164456530 |
| Fax Number: | |
| NPI Enumeration Date: | 02/26/2016 |
| NPI Last Update Date: | 05/20/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | 8097 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | SC |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |