1407918014 NPI number — PRIME DENTAL OF WOODRUFF

Table of content: (NPI 1407918014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407918014 NPI number — PRIME DENTAL OF WOODRUFF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME DENTAL OF WOODRUFF
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407918014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODRUFF
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29388-2117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-476-3212
Provider Business Mailing Address Fax Number:
864-476-3212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODRUFF
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29388-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-476-3212
Provider Business Practice Location Address Fax Number:
864-476-3212
Provider Enumeration Date:
12/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHIRLEY
Authorized Official First Name:
ASA
Authorized Official Middle Name:
DUNCAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
864-834-8001

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1863 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZA9487 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".