1548412968 NPI number — CHERAW FAMILY DENTISTRY

Table of content: (NPI 1548412968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548412968 NPI number — CHERAW FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERAW FAMILY DENTISTRY
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:
1548412968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1466
Provider Second Line Business Mailing Address:
3137 HWY 9 W
Provider Business Mailing Address City Name:
CHERAW
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-537-9044
Provider Business Mailing Address Fax Number:
843-537-5853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3137 HWY 9 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERAW
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-537-9044
Provider Business Practice Location Address Fax Number:
843-537-5853
Provider Enumeration Date:
10/16/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LANEY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
ROACHEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-537-9044

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4509 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 1642 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZX1642 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".