1144234063 NPI number — JOHN G MCROBERTS DMD PA

Table of content: (NPI 1144234063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144234063 NPI number — JOHN G MCROBERTS DMD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN G MCROBERTS DMD PA
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:
CLEMSON FAMILY DENTISTRY
Provider Other Organization Name Type Code:
5
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:
1144234063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 349
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEMSON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-654-5733
Provider Business Mailing Address Fax Number:
864-654-1117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 OLD CLEMSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SENECA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29672-8060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-654-5733
Provider Business Practice Location Address Fax Number:
864-654-1117
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
HIX
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
864-654-5733

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3718SC , 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: 122300000X . This is a "PROVIDER TAXONOMIES" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1223G0001X . This is a "PROVIDER TAXONOMIES" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: ZA9517 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZX1738 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3718 . This is a "SC LIC #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: ZX3718 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1738 . This is a "LIC# TN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 4110 . This is a "SC LIC #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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