1568673069 NPI number — UNIVERSITY DENTAL PA

Table of content: (NPI 1568673069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568673069 NPI number — UNIVERSITY DENTAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY DENTAL 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:
UNIVERSITY DENTAL LLC
Provider Other Organization Name Type Code:
3
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:
1568673069
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:
PO BOX 50664
Provider Second Line Business Mailing Address:
2329 DEVINE STREET
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-252-8101
Provider Business Mailing Address Fax Number:
803-779-7721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2329 DEVINE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-252-8101
Provider Business Practice Location Address Fax Number:
803-779-7721
Provider Enumeration Date:
05/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FELDER MCKELVEY
Authorized Official First Name:
LORETTA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER PRESIDENT CEO
Authorized Official Telephone Number:
803-252-8101

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  SC2642 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: DN013211 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 0401411265 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZ2642 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".