Provider Demographics
NPI:1023993912
Name:SOUTHERN TIDES DENTAL
Entity type:Organization
Organization Name:SOUTHERN TIDES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COACH
Authorized Official - Prefix:
Authorized Official - First Name:HOLLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOUST
Authorized Official - Suffix:
Authorized Official - Credentials:DA
Authorized Official - Phone:803-322-6020
Mailing Address - Street 1:1850 CREST RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-4305
Mailing Address - Country:US
Mailing Address - Phone:865-982-1700
Mailing Address - Fax:
Practice Address - Street 1:1701 BEAUCASTLE RD STE B
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3685
Practice Address - Country:US
Practice Address - Phone:843-258-8604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental