1174739056 NPI number — CAPITAL CHILDREN'S DENTAL CENTER, LLC

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 1174739056 NPI number — CAPITAL CHILDREN'S DENTAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL CHILDREN'S DENTAL CENTER, LLC
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:
1174739056
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:
139 WHITEFORD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29072-7965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-951-9100
Provider Business Mailing Address Fax Number:
803-951-1910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 SAINT ANDREWS RD
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-5112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-252-7725
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAINES
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
803-951-9100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , 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: ZA9467 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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