1013302785 NPI number — DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013302785 NPI number — DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL PROFESSIONALS OF SOUTH CAROLINA, P.C.
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:
6
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:
1013302785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 ASHBY PARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29607-6903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-987-5578
Provider Business Mailing Address Fax Number:
864-987-0351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 ASHBY PARK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29607-6903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-987-5578
Provider Business Practice Location Address Fax Number:
864-987-0351
Provider Enumeration Date:
03/31/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING TEAM LEAD
Authorized Official Telephone Number:
217-540-8972

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3791 , 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)





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